FaCilitator Manual Introduction to Agitation, Delirium ... · Describe the psychosis care pathway...
Transcript of FaCilitator Manual Introduction to Agitation, Delirium ... · Describe the psychosis care pathway...
English-haiti
Introduction to Agitation,
Delirium, and Psychosis
Curriculum for Psychologists/social Workers
FaCilitator Manual
IPartners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health (PIH) is an independent, non-profit organization founded over twenty years ago in Haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. Today, PIH works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.
PIH’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. PIH has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in Haiti. Through collaboration with leading medical and academic institutions like Harvard Medical School and the Brigham & Women’s Hospital, PIH works to disseminate this model to others. Through advocacy efforts aimed at global health funders and policymakers, PIH seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.
PIH works in Haiti, Russia, Peru, Rwanda, Sierra Leone, Liberia Lesotho, Malawi, Kazakhstan, Mexico and the United States. For more information about PIH, please visit www.pih.org.
Many PIH and Zanmi Lasante staff members and external partners contributed to the development of this training. We would like to thank Giuseppe Raviola, MD, MPH; Rupinder Legha, MD ; Père Eddy Eustache, MA; Tatiana Therosme; Wilder Dubuisson; Shin Daimyo, MPH; Noor Beckwith; Lena Verdeli, PhD; Ketnie Aristide; Leigh Forbush, MPH; and Jenny Lee Utech.
This training draws on the following sources: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association; Eapen, V., Graham, P., & Srinath, S. (2012). Where There Is No Child Psychiatrist: A Mental Health Care Manual. RCPsych Publications; Mental Illness Fellowship Victoria. (2013). Understanding psychosis; Raviola, Kahn, Jarvis. (2015). The Psychiatry Quality Program, Boston Children’s Hospital; Sherman, M. (2008). Support and Family Education: Mental Health Facts for Families, http://www.ouhsc.edu/safeprogram/; Starling, J., Feijo, I. (2012). Schizophrenia and Other Psychotic Disorders of Early Onset. In IACAPAP Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; Targum, S. D., & Busner, J. (2007). The Clinical Global Impressions Scale: Applying a Research Tool in Clinical Practice. Psychiatry, 4(7), 28; Winters, N., Hanson, G., & Stoyanova, V. (2007). The Case Formulation in Child and Adolescent Psychiatry. Child and Adolescent Psychiatric Clinics of North America, 16(1), 111–132; World Health Organization. (2010). mhGAP Intervention Guide. Geneva: World Health Organization; World Health Organization. (2010). Mental Disorders Fact Sheet 396, http://www.who.int/mediacentre/factsheets/fs396/en/.
We would like to thank Grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in Haiti.
© Text: Partners In Health, 2015 Photographs: Partners In Health Design: Katrina Noble and Partners In Health
II Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
This manual is dedicated to the thousands of health workers whose tireless efforts make
our mission a reality and who are the backbone of our programs to save lives and improve
livelihoods in poor communities. Every day, they work in health centers, hospitals and visit
community members to offer services, education, and support, and they teach all of us that
pragmatic solidarity is the most potent remedy for pandemic disease, poverty, and despair.
IIIPartners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Table of Contents
Introduction to Agitation, Delirium, and Psychosis
Introduction ...........................................................................1
Objectives .............................................................................2
Time Required ......................................................................4
Materials ..............................................................................5
Session 1: Introductions, Pre-test and Confidentiality ............6
Session 2: Epidemiology, the Treatment Gap and Stigma .....10
Session 3: Diagnosis of Severe Mental Disorders .................18
Session 4: The Psychosis System of Care and the FourPillars of Emergency Management of Agitation, Delirium and Psychosis ........................................................26
Day 1 Review: Group Presentations .....................................33
Session 5: Safety and Management of Agitated Patients ....34
Session 6: Medical Evaluation and Management of Agitation, Delirium, and Psychosis .......................................45
Session 7: Biopsychosocial Clinical Formulation ...................48
Session 8: Medication Management for Agitation, Delirium, and Psychosis .......................................................55
Day 2 Review: Jeopardy ......................................................61
Session 9: Psychotherapy and Family & Patient Education ...63
Session 10: Clinical Outcome Measures – CGI and WHODAS ..............................................................70
IV Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Session 11: Follow-Up and Documentation .........................81
Session 12: Using mhGAP for Psychosis and Bipolar Disorder ...................................................................83
Session 13: Review Session, Post-Test and Training Evaluation ..............................................................87
Annex
Pre-Test and Post-Test ........................................................96
Pre-Test and Post-Test Answer Key ...................................101
Psychosis Care Pathway .....................................................106
Differential Diagnosis Information Sheet for Severe Mental Disorders ...............................................................107
Agitation, Delirium and Psychosis Checklist .......................110
Agitated Patient Protocol ..................................................111
Agitation, Delirium and Psychosis Form .............................112
Medication Card for Agitation, Delirium, and Psychosis .....113
Medical Evaluation Protocol for Agitation, Delirium, and Psychosis ....................................................................116
Suicidality Screening Instrument ........................................118
Suicidality Treatment Guidelines ........................................119
Safety Plan ........................................................................121
Jeopardy Review Questions and Answer Key .....................122
Clinical Global Impressions Scale (CGI) .............................125
WHODAS 2.0 12 Item Version ..........................................127
Training Evaluation Form ...................................................131
Additional Resources:mhGAP Intervention Guide English: http://apps.who.int/iris/bitstream/10665/44406/1/9789241548069_eng.pdf
Diagnostic and Statistical Manual of Mental Disorders (DSM) IV
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 1
Introduction to Agitation, Delirium, and Psychosis
INTRODUCTION
Psychotic disorders refer to a category of severe mental illness that produces a loss of contact
with reality, including distortions of perception, delusions, and hallucinations. The most common
psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81 million
people. However, these two conditions do not account for all psychotic disorders. Despite the
immense burden of illness from psychotic disorders, about 80% of people living with a mental
disorder in low-income countries do not receive treatment.1 Stigma and discrimination against
people living with severe mental illness often result in a lack of access to health care and social
support. Human rights violations including being tied up, locked up, or left in inhumane facilities
for years; are all common.
Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical
evaluation to ensure that medical problems are not the root cause of the symptoms. The
term ‘agitated’ is often misused to describe patients who appear psychotic and are, therefore,
immediately referred to mental health. However, oftentimes these patients are actually
suffering from delirium, a state of mental confusion that can resemble a psychotic disorder
but is actually caused by a potentially severe medical illness. Patients who are delirious are
often injected with high doses of haloperidol to quell their ‘agitation’ and they frequently do not
receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement
can lead to death.
Fortunately, psychotic disorders are treatable and for some, completely curable. With the right
training and system of coordinated care, people with psychosis can receive effective treatment
and lead rich, productive lives. In this training, psychologists and social workers will learn how
to manage agitated patients safely and effectively and will also learn how to properly diagnosis
psychotic disorders caused by mental illness. By the end of this training, psychologists and
social workers will understand how to work hand-in-hand with community health workers,
nurses and physicians to provide high-quality, humane medical and mental health care for
agitated, delirious, and psychotic patients.
1. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
2 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
OBJECTIVES
By the end of this training, participants will be able to:
Session 1:a. Describe the purpose of the training.
b. Establish ground rules that create a respectful and trusting environment.
c. Demonstrate prior knowledge of the training topic.
Session 2:d. Identify participants’ current and past attitudes surrounding severe mental illness.
e. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.
f. Describe the various ways that psychosis may be viewed by the community and by health providers.
g. Describe the impact of stigma on patient care and outcomes.
Session 3:h. Identify key clinical information related to the diagnosis of various psychotic disorders.
i. Develop a basic mental health differential diagnosis using the Differential Diagnosis Information Sheet.
Session 4:j. Describe the psychosis care pathway and its collaborative care approach.
k. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care.
l. Explain the four pillars of emergency management of agitation, delirium and psychosis.
m. Describe how a psychologist/social worker should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.
Session 5:n. Describe the identification, triage, referral, and non-pharmacological management of an
agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.
o. Explain how to screen for suicidal ideation and manage suicidal patients consistent with their severity and risk level.
Session 6:p. Define medical delirium.
q. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 3
r. Explain the process of carrying out a medical evaluation for an agitated, delirious or psychotic patient.
Session 7:s. Explain how to gather information for a complete mental health history.
t. Describe how to create a biopsychosocial clinical formulation to guide a patient’s treatment.
Session 8:u. Explain the collaboration between the physician and the psychologist/social worker in
managing medication for agitation, delirium and psychosis.
v. Describe the physician’s use of the Medication Card for Agitation, Delirium and Psychosis.
Session 9:w. Explain the core psychotherapy approaches for patients with severe mental illness.
x. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders.
Session 10:y. Describe how to use the CGI and WHODAS to assess clinical improvement.
z. Explain the importance of outcome measures to assess care quality and systems improvement.
Session 11:aa. Explain the process of follow-up for people living with psychotic disorders and severe
mental illness.
ab. Describe the importance of documentation during patient follow-up.
Session 12:ac. Describe how to use mhGAP for the management of psychosis and bipolar disorder.
ad. Describe how to use mhGAP for the management of self-harm/suicide.
Session 13:ae. Review all unit objectives.
af. Demonstrate learning through a post-test.
ag. Give feedback on the training.
4 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
TIME REQUIRED 3½ days (19 hours and 10 minutes of training sessions)
DAY 1: 5 hours and 15 minutes of training sessions
Session Content Methods Time
1Introductions, Pre-Test and Confidentiality
• Facilitator presentation• Icebreaker• Assessment
1 hour 45 minutes
2Epidemiology, the Treatment Gap, and Stigma
• Reflection journey• Facilitator presentation• Role play
1 hour 15 minutes
3Diagnosis of Severe Mental Disorders
• Facilitator presentation• Case studies
1 hour 15 minutes
4
The System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis
• Facilitator presentation• Large group discussion• Case studies
1 hour
DAY 2: 5 hours 40 minutes of training sessions
Session Content Methods Time
Review Day 1 Review • Group presentations 30 minutes
5Safety and Management of Agitated Patients
• Facilitator presentation• Role play
2 hour
6Medical Evaluation and Management of Agitation, Delirium and Psychosis
• Facilitator presentation 30 minutes
7Biopsychosocial Clinical Formulation
• Facilitator presentation• Small group work
1 hour
8Medication Management of Agitation, Delirium and Psychosis
• Facilitator presentation• Worksheet• Role play
1 hour 10 minutes
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 5
DAY 3: 5 hours and 45 minutes of training sessions
Session Content Methods Time
Review Day 2 Review • Jeopardy 1 hour
9Psychotherapy and Family & Patient Education
• Facilitator presentation• Case Study
1 hour 15 minutes
10Clinical Outcome Measures: CGI and WHODAS
• Facilitator presentation• Role Play
2 hours
11Follow-Up and Documentation • Facilitator presentation
• Small group work45 minutes
12Using mhGAP for Psychosis and Bipolar Disorders
• Facilitator presentation• Role Plays
45 minutes
DAY 4: 2 hours 30 minutes of training sessions
Session Content Methods Time
13Review, Post-Test and Training Evaluation
• Case studies• Assessment• Reflection
2 hours 30 minutes
MATERIALS NEEDED
Materials
� Facilitator Manuals — 1 copy/facilitator
� Participant Handbooks — 1 copy/participant
� Agitation, Delirium, and Psychosis PowerPoint presentation
� Jeopardy PowerPoint
� DSM IV (participants should bring their own copies)
� mhGAP — 1 copy/participant (for optional Session 12)
� Computer and Projector
� Flip chart
� Markers
� Post-it Notes (estimate 7/participant)
� Tape
6 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 1: Introduction, Pre-Test and Confidentiality
Methods: Facilitator presentation, ice breaker and assessment
Time: 1 hour 45 minutes
Materials: � PowerPoint presentation (Agitation,
Delirium, and Psychosis slides 1– 9) � Pre-Test (1 copy/participant) � Flip chart or chart paper
� Markers, pens � Tape � Post-it notes
Preparation:
• Review PowerPoint (Agitation, Delirium and Psychosis), slides 1– 9.• Post a blank sheet of paper on the flip chart and title it “Goals & Expectations.”• Post a blank sheet of paper on the flip chart and title it “Training Rules.”
• Photocopy the pre-test (see appendix).
Objectives:a. Describe the purpose of the training.b. Establish ground rules that create a respectful and trusting environment.c. Demonstrate prior knowledge of the training topic
NOTE FOR FACILITATOR PREPARATION
General Tips for Presenting PowerPoint (PPT) Slides:
When presenting PowerPoint slides, it is not necessary to read everything on each slide. Instead, summarize the main ideas on the slide and add any supplemental information that will help the audience to understand the most important ideas.
Encourage participant feedback during PowerPoint presentations. Some slides have a clinician depicted with a conversation bubble that is intended to look like she is asking a question. Use her conversation prompts to ask the audience questions and hear their feedback before clicking forward to reveal the answers..
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 7
STEPS
20 minutes
1. Turn on projector and begin the PowerPoint at Slide 1: Agitation, Delirium and Psychosis. Welcome participants, introduce yourself and this training. Tell the participants that this training is about management of agitation, delirium and psychosis.
2. Show Slide 2: Session 1: Welcome and Learning Objectives.
Read the objectives on the slide.
3. Show Slide 3: Building a System of Care.
Explain how this training ties into past trainings on depression and epilepsy. Tell the participants that taken together, these three trainings articulate the beginnings of a coherent community-based system of mental health care. Tell the participants that a community-based system of care facilitates:
• High-quality care (safe, effective, evidence-based and culturally attuned) that keeps patients in their local communities, resulting in less socioeconomic burden on families.
• Comprehensive medical evaluation.
• Multi-disciplinary and biopsychosocial approach to care involving physicians, nurses, community health workers, psychologists/social workers.
• Humane care that does not involve institutionalizing patients for years or traumatizing them by tying them up, beating them, or injecting them with high doses of medication.
4. Show Slide 4: Psychosis Care Pathway.
Tell the participants that they may remember seeing similar care pathways for both de-pression and epilepsy. These pathways guide how these mental health issues are handled in Zanmi Lasante’s community-based mental health system of physicians, psychologists, social workers, nurses and community health workers. Tell the participants that today we will be introducing a similar care pathway for psychosis. Allow the participants to look at the various responsibilities of the health providers in the psychosis system of care. Explain that the participants will be seeing this model throughout the training.
5. Show Slide 5: Zamni Lasante Mental Health.
Explain that since the development of the community-based system of mental health care, Zamni Lasante has been able to identify and treat many patients with various mental health issues.
6. Turn off the projector (or cover the lens).
8 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
40 minutes
7. Pass out one Post-it note to each participant. Ask participants to take a minute and write down one goal or expectation that they have for this training. Then, have all the participants introduce themselves and share their goal. After each person speaks, post their Post-it note to the flip chart entitled “Goals and Expectations.”
8. Assure the participants that many of these goals and expectations will be met during the training. Others will be addressed through monthly meetings and ongoing communication with the participants.
9. Explain that in order to ensure an effective training, the group will follow some ground rules. Invite participants to brainstorm ground rules. Write the ground rules on a sheet of chart paper and keep it posted during the training. Ground rules can include: punctuality; confidentiality; participation in discussions and activities; respect for different opinions; cell phones off.
CONFIDENTIALITY
Confidentiality is one of the most important parts of being a clinician. You must keep everything that family members tell you, and everything that you know about their condition, confidential. You should only share such information with other clinicians when needed.
Some of you may reference confidential patient information during the training. You must share or ask in a way that maintains confidentiality. For example, do not use the person’s name, say where she or he lives, or give any other information that would reveal the person’s identity. Also, you must not talk about confidential information outside of this training.
10. Designate someone as the “time keeper.” The role of the time keeper is to keep the training running smoothly by being aware of time, and signaling to the facilitator when there is five minutes left in a session. The time keeper should have a watch or cell phone.
11. Write “parking lot” on a piece of Flip chart paper and hang it on the wall. Tell participants that when a question is raised that might not be answerable or relevant at that particular moment, it will go to the “parking lot.” By the end of the training all questions in the parking lot will hopefully be answered, and if not, the facilitators will guide participants to the resources to answer remaining questions.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 9
30 minutes
12. Distribute the pre-test and explain how it should be completed.
13. Collect the completed pre-tests.
14. Explain that the participants will take a post-test at the end of the training in order to measure what they have learned.
15 minutes
15. Explain to the participants that they have materials and resources that will be referred to throughout the training. The materials and resources will also be a resource to them once the training is over. Tell them that they can refer to the training materials when they are seeing patients or need clarification on the topics covered in the training.
16. Have participants turn to the agenda in their participant handbooks. Tell them that the training is divided into a series of sessions as they can see listed in the agenda.
17. Tell the participants that each session has learning objectives associated with it. Tell them that the learning objectives represent what they should learn during each session of the training. The participants should re-visit the learning objectives throughout the training to assure that they are meeting the expectations for the training. Request that the participants ask for clarification or more information if ever they feel like they do not meet a learning objective.
18. Tell the participants that the additional materials will be distributed and explained as the training progresses.
19. Remind the participants that they are responsible for their own learning in some ways. As such, encourage the participants to ask questions throughout the training, especially if they do not feel like they are able to fulfill the training objectives.
20. Turn on the projector (or uncover its lens).
21. Show Slides 6 – 9: Learning Objectives.
Animate and read each objective (ask a participant to read the objectives aloud or do so yourself). Tell the participants that these objectives will be covered by the training in the next three and a half days.
10 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 2: Epidemiology, the Treatment Gap, and Stigma
Methods: Reflection journey, facilitator presentation, role play
Time: 1 hour 15 minutes
Participant Handbook page: 4
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 10 –18 � Flip chart � Markers
Preparation:• Practice implementing the Reflection Journey.
• Review the PowerPoint (Agitation, Delirium, and Psychosis), slides 10 –18.
Objectives:d. Identify the participants’ current and past attitudes surrounding severe mental illness.e. Describe the epidemiology of psychotic disorders and the corresponding treatment gap. f. Describe the various ways that psychosis may be viewed by the community and by
health providers.g. Describe the impact of stigma on patient care and outcomes.
STEPS
20 minutes
1. Show Slide 10: Session 2: Epidemiology, Treatment Gap and Stigma.
Read the objectives and explain to participants that the group will begin to discuss psychotic disorders.
2. Ask the participants to begin by closing their eyes or putting their heads down. Explain that you will take them through a ‘Reflection Journey’— some quiet thinking before a large group discussion.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 11
3. Once the participants are ready, lead them through the following ‘Reflection Journey’. Be sure to pause for 5 – 10 seconds after each question to allow the participants to reflect. Keep in mind that you do not need to ask every question (and you may add any questions that might be more relevant).
When you hear the word “psychosis”:
• What words come to mind?
• What images come to mind?
Think back to a time when you were very young:
• How did you learn about psychosis? What were your thoughts or feelings about it?
• What words did you hear and use related to psychosis?
• What did you think or feel about people with psychosis?
Think about your life since then:
• How have your thoughts about psychosis changed?
• What events or experiences changed the way you think or feel about psychosis?
• In what ways have your ideas about psychosis remained the same?
4. Ask participants to open their eyes. Invite a few volunteers to share their thoughts (maintaining patient and family confidentiality), and lead a brief discussion during which you discuss participants’ past and current experiences with psychosis.
5. Ask the participants if they think their understanding and views around psychosis and severe mental illness are different than their patients’. If so, ask the participants to elaborate on how patients and families might interpret psychosis. Write the participants’ ideas on a flip chart as they share their ideas.
6. Emphasize the importance of understanding that patients and families might have different understandings than psychologists/social workers as to why someone has psychosis. Explain that each person and family, depending on their personal and cultural background, has an “explanatory model of illness”, which helps them to understand and make sense of their experience. Explain that participants are going to be introduced to some biomedical terms in this training, but it is important to note that using these terms with patients is less important than understanding patients’ and families’ experiences. It is important to help families feel heard and understood, and psychologists/social workers can do this by avoiding medical jargon and instead engaging with patients on their level.
12 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
40 minutes
7. Show Slide 11: Psychosis.
Animate the speech bubble. Ask the participants the following question:
• What is psychosis?
Wait for a few responses, and then respond by animating the answer. Tell the participants that there are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder and autism spectrum disorder.
8. Show Slide 12: Schizophrenia.
Animate the speech bubble. Ask participants the following question:
• How would you define schizophrenia?
Wait for a few responses, and then respond by animating the answer.
9. Show Slide 13: Bipolar Disorder.
Animate the speech bubble. Ask participants the following question:
• What is bipolar disorder?
Wait for a few responses, and then respond by animating the answer. Tell the participants that many symptoms of anxiety tend to be confounded with mania. Psychologists/social workers should pay close attend to the signs and symptoms of bipolar disorder.
10. Show Slide 14: Schizophrenia and Bipolar Disorder: The Global Burden.
Animate the speech bubble. Ask participants the following question:
• How many millions of people are affected by schizophrenia and bipolar disorder?
Wait for a few responses, and then respond by animating the answer. Tell the participants that approximately 1 in 100 people globally lives with a psychotic illness.
11. Ask the participants to reflect upon the following question:
• As we just learned, people with schizophrenia/bipolar disorder have a reduced life expectancy. Why do you think this is?
Have the participants share their answer with the person sitting next to them, and then have the pairs share their ideas with the group.
12. Explain that there are many reasons for reduced life expectancy, some of which are consequences of what we call the “treatment gap.”
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 13
13. Show Slide 15: Treatment Gap.
Animate the speech bubble. Ask the participants the following question:
• What does “treatment gap” mean?
Wait for a few responses, and then respond by animating the answer. Tell the participants that the two most common severe mental illnesses are schizophrenia and bipolar disorder.
14. Explain that health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.2
15. Show Slide 16: Reasons for the Treatment Gap.
Animate the title. Ask participants to specifically share why they think there is a treatment gap. After all ideas have been given, respond by animating the text on the slide.
16. Show Slide 17: Consequences of the Treatment Gap.
Animate the title. Ask participants the following question:
• What are the consequences of this treatment gap in Haiti?
Allow participants to respond. Animate the picture and text. Explain to the participants that lack of awareness around mental health treatment often leads to abuse and mistreatment of those living with severe mental illness.
17. Show Slide 18: Consequences of the Treatment Gap.
Explain that lack of treatment can have direct effects on the physical health of those living with severe mental illness. This photo is of a girl with epilepsy who fell into a fire when she had a seizure.
2. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
14 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
18. Explain that the treatment gap directly affects society’s concepts of severe mental illness and leads to stigma and discrimination of those with severe mental illness. Use the exercise below to demonstrate this concept further.
Ask the following questions sequentially to the participants:
Raise your hand if:
1. You have been to a doctor’s appointment during the last year.
– Wait for the participants to raise their hands.
2. You were admitted to a hospital for any reason during the past year.
– Wait for the participants to raise their hands.
3. You have taken any medication during the last year.
– Wait for the participants to raise their hands.
Ask participants how it felt to answer these questions in this group setting. Allow participants to respond.
Now say:
If we were to ask you to raise your hand (BUT no need to raise your hand) if…
1. You saw a mental health professional during the past year.
2. You were admitted to a psychiatric hospital, such as Mars and Kline, for any reason during the past year.
3. You have taken any psychiatric medication during the last year.
….how would you feel? Why?3
Have the participants share how they felt during this exercise.
19. Tell the participants:
Even though we are providers of mental health care, and understand the epidemiology behind severe mental illness, we can still feel stigma towards severe mental illness. This can lead to discrimination and unfair or low-quality treatment of patients.
3. Sherman, M. (April 2008). Support And Family Education: Mental Health Facts for Families. Retrieved from: http://www.ouhsc.edu/safeprogram/
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 15
STIGMA
Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.
20. Highlight the fact that, as clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.
15 minutes
21. Tell the participants that they are now going to role play how providers can perpetuate stigma in their work with people with severe mental disorders — sometimes without even realizing it.
22. Ask for three volunteers to participate in the role play. Assign one volunteer to be the patient, one volunteer to be the nurse, and one volunteer to be the family member. Give the three volunteers two to three minutes to read over the role play found in their participant handbook (refer to Facilitator Notes). Tell the volunteers that the ‘story’ section of the role play is intended to give the role play participants key background information, however, the participants should just use the script when performing.
23. Invite the role play volunteers to the front of the room to complete the role play about stigma.
16 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTES
STIGMA ROLE PLAY
STORY
A patient is brought by his family to the emergency room. He is very talkative and focuses mainly on vodou and religion. The emergency nurse fears that he is violent and does not wish to touch him because she thinks he may hit her. The nurse does not check vital signs or provide any medical care. Instead the nurse calls the psychologist/social worker on the phone and says “a mental health patient is here.” In the meantime, the patient is totally dehydrated, and has both a high fever and pulse that go undetected. His family reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his mother wait and no one comes to them for help.
SCRIPT
Family Member (Participant 2): Brings in sick patient to the emergency room.
Patient (Participant 1): Arrives to emergency room in the arms of a family member. Begins to talk a lot about vodou and religion in the emergency room.
Nurse (Participant 3): Acts scared because he might be violent. Calls psychologist/social worker to say a mental health patient is here.
Patient (Participant 1): Has a fever and becomes dehydrated. Does not look well.
Family Member (Participant 2): Reports to nurse that patient has never behaved this way before and only became “a crazy person” after a dog bit him. Becomes frustrated that a lot of time has passed and no one has helped them.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 17
24. After the role play, ask the following question:
• Which of the nurses’ actions might have perpetuated the stigma around people with severe mental disorders?
• What should have been done?
• Has anyone ever encountered a similar situation in their work? What was done well or done poorly by the clinician in those situations?
25. Tell the participants:
The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Psychologists/social workers have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Psychologists/social workers have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.
18 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 3: Diagnosis of Severe Mental Disorders
Methods: Facilitator presentation, large group discussion, case studies
Time: 1 hour 15 minutes
Participant Handbook page: 8
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 19 – 33 £ DSM IV (participants should bring their own copies)
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 19 – 33.• Identify pages in DSM IV that have diagnostic criteria for illnesses outlined in steps 11–18.
Objectives:h. Identify key clinical information related to the diagnosis of various psychotic disorders.i. Develop a basic mental health differential diagnosis using the Differential Diagnosis
Information Sheet.
STEPS
40 minutes
1. Show Slide 19: Session 3: Diagnosis of Severe Mental Disorders.
Tell the participants that they will review the basics of diagnosing mental health problems that fall under the umbrella of “severe mental illness.” Explain that the participants will use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), as a guide to frame the discussion. The DSM IV is used in the United States and is similar to The International Classification of Diseases, Tenth Revision (ICD-10) that is used in other parts of the world.
2. Show Slide 20: Defining Severe Mental Disorders.
Ask the participants.
• What is a severe mental disorder and how is this different than a common mental disorder?
Wait for a few responses, and then respond by animating the answer.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 19
3. Show Slide 21: Psychosis: Positive and Negative Symptoms.
Read the points on the slide, emphasizing that each patient could have a combination of symptoms — they do not need to have them all to be psychotic. Explain that negative symptoms are the opposite of what is expected in a normally behaving person.
4. Show Slide 22: Phases of Psychosis.
Explain that there are three distinct phases of psychosis that psychologists/social workers will see throughout their work with psychotic patients: the prodromal phase, the acute phase and the stable phase.
5. Show Slide 23: Range of Psychotic Disorders.
Animate speech bubble. Ask the participants the following question:
• Who can name a psychotic disorder?
Wait for a few responses, and then respond by animating the answer.
6. Ask the participants if they understand what the text on the bottom of the slide means: “A medical delirium, which looks like a psychosis, is not a psychotic disorder. It is a medical emergency!” Take answers.
Tell the participants that delirium is a medical condition that produces a disturbance in attention and awareness. A delirious person might have psychotic symptoms, however they do not have a mental illness, they have a medical illness. Once the medical illness is treated, the psychotic symptoms disappear.
DELIRIUM
Delirium is a disturbance in attention and awareness due to a medical illness. A medical delirium can appear like psychosis; however it is not a psychotic disorder!
7. Explain to the participants that there is a Differential Diagnosis Information Sheet in their participant handbook that outlines various severe mental illness diagnoses. Have the participants open their participant handbooks to the Differential Diagnosis Information Sheet located in the annex. Give the participants a few minutes to review the document.
20 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
8. After a few minutes, ask the participants to describe the way in which the Differential Diagnosis Information Sheet is organized. Take a few answers. Explain that:
• The Differential Diagnosis Information Sheet begins with the category of psychosis-appearing symptoms due to medical conditions. Later in the training psychologists/social workers will learn about physicians’ roles in determining if a patient has a medical illness or mental illness.
• The second category on the Differential Diagnosis Information Sheet describes mental health issues that are NOT psychosis.
• The third and fourth categories describe psychotic or manic disorders, and these categories are divided up by “episodic” illnesses and “continuous” illnesses.
Ask if there are any questions on how the Differential Diagnosis table is organized.
9. Show Slide 24: Psychosis: Mimics.
Tell the participants that there are some medical conditions and mental health conditions that may look like psychosis, but are not. These include all the conditions in the first two categories on the first page of the Differential Diagnosis Information Sheet. These conditions should still be treated by a psychologist/social worker and physician, but today’s training will not focus on these conditions. Ask if there are any questions about psychosis mimics on page one of the Differential Diagnosis Information Sheet.
10. Have the participants go to the next page to the “Episodic Psychosis or Mania” section. Explain that symptoms that are present for less than six months are considered episodic. Tell them that this category includes both mood disorders (depression with psychotic features and bipolar disorder) and psychosis.
11. Show Slides 25 – 26: Severe Depression with Psychotic Features.
Ask for participants to open their DSM IV. Have them find this diagnosis in the DSM and follow along. Read the slide aloud.
12. Show Slide 27: Bipolar Disorder.
Have the participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud. Tell them that bipolar disorder is diagnosed when a patient has at least one manic episode. Explain that:
• Bipolar disorder usually starts during adolescence and early adulthood. It is not common that bipolar disorder develops in children who have no family risk factors and it is rare that it develops in people over 60 years (except when associated with another disease).
• Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Some people may have as many maniac a. depressive episodes, while others may experience one type of episode (usually depression). If you are not sure which episodes the patient has had, document it as bipolar unipolar.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 21
• Hypomania is a less severe form of mania, with similar symptoms, but less severe. Hypomania has a less of a negative impact on the daily activities of the person.
• Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half of people go on to experience a new episode of mania or major depression within the next two years.
13. Show Slide 29: Brief Psychotic Disorder.
Have the participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud. Tell participants that in the DSM a brief psychotic disorder can only be diagnosed if the episode lasts less than 1 month.
14. Show Slide 30: Schizophreniform Disorder.
Have participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud. Tell participants that the main difference between brief psychotic disorder, schizophreniform disorder and schizophrenia is the duration of the symptoms/episode. Schizophreniform can be diagnosed if symptoms are present for 1 – 6 months only.
15. Show Slide 31: Psychosis NOS.
Have the participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud. Ask if anyone has ever encountered a patient that they thought should be diagnosed with Psychosis NOS, and if so, ask for that participant to share their experience with the symptoms and diagnosis of the patient.
16. Explain to the participants that symptoms that are present for more than six months are considered continuous, which includes the illnesses of schizophrenia and delusional disorder.
17. Show Slide 32: Schizophrenia.
Have the participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud. Explain that:
• Schizophrenia is thought to be caused by physical changes in the brain, however it may begin after a stressful event.
• Schizophrenia may begin at any time but most commonly it begins in the mid- to late teens or early 20s.
• Prior to developing schizophrenia, patients may show subtle nonspecific signs such as depression, social withdrawal, and irritability.
• Patients can have periods of stability with or without treatment during which their symptoms are absent or minimal.
22 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Emphasize that among adults, hallucinations are viewed as synonymous with psychosis and as harbingers of serious psychopathology. In children, however, hallucinations can be part of normal development or can be associated with non-psychotic psychopathology, psychosocial stressors, drug intoxication, or physical illness. The first clinical task in evaluating children and adolescents who report hallucinations is to sort out those that are associated with severe mental illness from those that derive from other causes.
18. Show Slide 33: Delusional Disorder.
Have the participants find this diagnosis in the DSM and follow along. Ask for a participant to read the slide aloud.
35 minutes
19. Tell the participants that they will now practice using the Differential Diagnosis Information Sheet for four different cases. Tell the participants they will be divided into four groups. Each group will be assigned a case and will have 10 minutes to complete the questions related to their case. The participants will use their Differential Diagnosis Information Sheet to help determine a diagnosis.
20. After 10 minutes has elapsed, bring the class back together. Invite each group to read their case studies aloud and give their answers.
21. Conclude by telling the participants that proper diagnosis of severe mental illness is one of the key responsibilities of the psychologist/social worker in the system of care. This includes making an accurate diagnosis and not overdiagnosing severe mental disorders such as schizophrenia and bipolar disorder. Misdiagnosis leads to poor treatment and overmedication.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 23
FACILITATOR NOTES
DIFFERENTIAL DIAGNOSIS CASE STUDIES
*For all cases assume that a medical illness has already been ruled out by the physician. All the patients referred to you have been determined to have a mental illness.
CASE STUDY 1
A mother has brought her 12-year-old girl to the health facility. She says that her daughter is often unfocused, seemingly “far away.” The daughter sometimes wakes up in the middle of the night screaming. The girl refuses to enter any cars. Through questioning the mother, you find out that this has been happening for 7 weeks. The girl has had difficulty falling asleep, has been sleeping poorly, and reports that sometimes she sees “shadows of people” at night who are not there. The mother reveals that their son died in a car accident about two months ago, and that the daughter was in the car when it happened. After performing a mental status exam, taking a history and asking the patient a few questions about her friends and school, you see she has no evident problems with cognition or emotion. There is no history of mental illness in the family.
1. Is the girl, in your opinion, psychotic? Why or why not?
• No. She does not seem to have dysfunction in cognition, behavior or emotion. There are no positive and negative symptoms present. Although she may see “shadows” at night, this does not mean that she has psychosis. Often when people, particularly children and young people, have stress they can both hear and see things that may not be present. This is usually not psychosis. It is important to remember that while true psychosis develops in the late teen and early adult years, it is extremely uncommon in children younger than 12. In this case, to diagnose psychosis and to prescribe an antipsychotic medication would do more harm to the girl than good. Antipsychotic medication could cause unwanted medication side-effects, such as diabetes or permanent abnormal muscle movements.
2. What diagnosis might you present to the girl? Why?
• Acute stress, anxiety or trauma related problem.
• She has been in a traumatic event and is experiencing transient sensory experiences, like nightmares and flashbacks. She is anxious to enter cars. Helping her to cope with the loss of her brother, and the terrible experience of being in the car when the accident happened, should be the focus of treatment. This should be done in close collaboration with a supervising psychologist who can advise on the most effective and safest approach to treatment.
24 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CASE STUDY 2
A 22-year-old woman is brought in by her husband. He says that his wife has been acting strangely recently. He reports that she has refused to get out of bed for the past week and has been crying frequently. He was worried she was depressed. However, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe the wife chatting excitedly with other people in the waiting room. She says she feels wonderful and doesn’t know why her husband brought her here. The husband reports that over the past few days she has been spending the family’s money on nonessential items and that he is worried that this is putting the family at risk.
1. Is the woman, in your opinion, psychotic? Why or why not?
• The behavior of the woman is concerning. The history provides evidence of real depression, followed by mania. Being in a good mood is a good thing, but if the mood is so elevated that it seems abnormal, and if the associated behavior puts the person or others around the person at risk, this is concerning for mania. However, the woman does not hear voices and does not have symptoms that are clearly indicative of psychosis.
2. What diagnosis might you present to the woman? Why?
• Bipolar disorder with mania and depression. She has periods of elation and depression. She has had a manic episode characterized by a decreased need for sleep, is more talkative than usual and is involved in pleasurable activities that have a high potential for consequences. She also has periods of depression where she stays in bed and cries.
CASE STUDY 3
A 20-year-old man is brought in by his friend. The friend says that recently, the patient started saying that his neighbor is watching him all the time. The patient cannot stop talking about the neighbor’s spying. The patient describes that he even hears what the neighbor is saying about him in his mind. When you ask how long this has been happening for, the friend says almost three months.
1. Is the man, in your opinion, psychotic? Why or why not?
• Yes. He has dysfunction in cognition and behavior. He is experiencing delusions and hallucinations.
2. What diagnosis might you present to the man? Why?
• Possibly schizophrenia, but it has not been long enough to be diagnosed. At this time schizophreniform disorder would be diagnosed because the issue has been occurring for more than three months. The clinician should be cautious about making a diagnosis of schizophrenia because six months have not yet passed.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 25
CASE STUDY 4
A 25 year-old man is brought in by a neighbor. This patient has disorganized behavior and has not bathed recently. He is mumbling words under his breath and is not able to speak in complete sentences. You try to have a conversation with the patient, but cannot easily communicate. You ask the neighbor how long he has been like this. The neighbor responds that he has been like this for a few years already, but this is the first time that he is seeing a psychologist/social worker. The neighbor says that the man cannot work because of his mental state and sometimes the man is aggressive and yells threats to no one in particular. What diagnosis might you present to the man?
1. Is the man, in your opinion, psychotic? Why or why not?
Yes. He has dysfunction in cognition and behavior. It is reported that he is experiencing hallucinations.
2. What diagnosis might you present to the man? Why?
Schizophrenia. He has hallucinations, disorganized speech and disorganized behavior for more than six months. Since the onset of the disturbance his ability to work and self-care has been affected.
26 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 4: The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis
Methods: Facilitator presentation, large group discussion, case studies
Time: 1 hour
Participant Handbook page: 17
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 34 – 52 � Flip chart
� Markers � Tape
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 34 – 52
Objectives:j. Describe the Psychosis Care Pathway and its collaborative care approach.k. Outline the main roles of physicians, psychologists, social workers, nurses, and community
health workers in the system of care.l. Explain the four pillars of emergency management of agitation, delirium, and psychosis.
m. Describe how a psychologist/social worker should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.
STEPS
20 minutes
1. Show Slide 34: The System of Care and the Four Pillars of Emergency Management of Agitation, Delirium and Psychosis.
Explain to the participants that you will discuss how Zanmi Lasante clinicians will facilitate care for complex patients, including psychotic patients.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 27
2. Show Slide 35: Discussion About Psychosis Care Pathway.
Tell the participants that psychologists and social workers main roles in the Zanmi Lasante system of care are:
a. to ensure safety for the patient and others through correct agitation management;
b. to make a preliminary diagnosis of delirium/medical illness or mental illness in coordination with the physician;
c. to provide psychotherapy and psychoeducation to patient and families;
d. to coordinate care with the physician and CHW.
Explain that psychologists/social workers are just one important element in the collaborative care approach; to provide the quality care they need to work closely with other team members that include physicians, nurses and community health workers.
3. Have the participants turn to the Agitation, Delirium and Psychosis Checklist in their participant handbooks. Explain that all cadres will be receiving this checklist, which is an outline of key responsibilities. Give participants several minutes to read the checklist. Once the participants have finished reading it over, read the “Psychologist/Social Worker” column aloud, going through each responsibility. Ask if there are any questions.
4. Show Slide 36: Psychosis System of Care Responsibilities.
Explain this is a summary of the checklist responsibilities for each cadre.
5. Assess the participants’ understanding of the checklist by asking the questions below. Call randomly on participants. If a participant is unable to answer correctly, ask if another participant might be able to assist with the correct answer. Give participants at least 1 – 2 minutes to look for an answer before calling on someone else.
1. According to the psychosis care pathway, which providers are responsible for deciding if a patient has a medical problem or psychological disorder?
– Psychologists and physicians work together to determine whether patients have a medical problem or a psychotic disorder (a mental health problem).
Animate slide 37: Question 1: Psychologists & Physicians
2. According to the psychosis care pathway, which providers are responsible for managing an agitated patient?
– Physicians, psychologists/social workers, and nurses work together to manage agitated patients. However, physicians are expected to take the lead, due to the need for prompt medical evaluation to rule out a treatable medical condition, and to possibly prescribe an initial medication for either a medical or mental health problem.
Animate slide 38: Question 2: Physicians, Psychologists & Nurses
28 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. According to the psychosis care pathway, which providers are responsible for giving psychoeducation?
– All providers.
Animate slide 39: Question 3: All Providers
4. According to the psychosis care pathway, how should physicians collaborate with psychologists/social workers during the initial evaluation of a calm patient and the follow-up visit for a calm patient?
– During an initial visit: to diagnose delirium/medical illness or mental disorder and to plan follow-up visits.
– During a follow-up visit: to determine whether a patient is improving and to plan follow-up visits.
Animate slide 40: Question 4: Diagnose Delirium/Medical Illness, Plan Follow-Up visits, Patient Improvement.
6. Show Slide 41: Psychosis Care Pathway.
Animate the slide. Tell the participants to turn to their neighbor and discuss for five minutes the questions on the slides. After five minutes, bring the participants together and ask for the participants to share some of their ideas.
7. Show Slide 42: Tools Used by Physicians with Which Psychologists/Social Workers Should be Familiar.
Explain that psychologists/social workers and physicians each have their responsibilities in the system of care that require tools. There are some diagnostic tools that are only used by physicians, however, psychologists/social workers should be familiar with these tools.
8. Show Slide 43: Tools Used by Psychologists/Social workers with Which Physicians Should be Familiar.
Explain that there are other tools only used by psychologists/social workers.
9. Show Slide 44: Tools Used by Both Psychologists/Social Workers and Physicians.
Emphasize that these tools will be used by both psychologists/social workers and physicians.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 29
40 minutes
10. Show Slide 45: Four Pillars of Emergency Management of Agitation, Delirium and Psychosis.
Explain that psychologist’s responsibilities in the care pathway align with the four pillars of managing a patient with psychotic symptoms. Emphasize that these pillars lay the framework for how clinicians manage patients with psychotic symptoms. Tell the partici-pants that they will be coming back to these pillars throughout the training.
11. Show Slides 46: How do These Pillars Direct our Thinking and Aaction with Psychotic Patients?
Explain that there are several steps and processes within each pillar that the participants will learn to address when confronted with a psychotic patient. Read the slide and explain that these are some of the main steps that will guide all cadres of health workers to provide appropriate care for a patient with psychotic symptoms.
12. Show Slide 47: Biopsychosocial Model.
Explain that clinicians need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.
Explain to participants that a biopsychosocial approach to mental health treatment, will:
• Assist with understanding the condition
• Assist with structuring assessment and guiding intervention
• Inform multidisciplinary practice
13. Show Slide 48: Biopsychosocial Considerations.
Animate the title. Ask the participants what biological considerations psychologists and social workers should have when working with patients with psychotic symptoms. Once they have responded, animate the “bio” column.
Ask the participants what psychological considerations psychologists and social workers should have when working with patients with psychotic symptoms. Once they have responded, animate the “psycho” column.
Ask the participants what social considerations psychologists and social workers should have when working with patients with psychotic symptoms. Once they have responded, animate the “social” column.
Emphasize that the biopsychosocial approach to evaluation will lead to better identification of problems, communication between providers, and care for patients.
30 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
14. Show Slide 49: Case 1.
Animate the slide. Ask for a volunteer to read the case aloud. Remind the participants they did a role play earlier today based on this case. Ask the participants to think about the four pillars of emergency management and how they can apply the pillars to this case.
15. Show Slide 50: Case 1: How Should We Think About Mental Health?”
Animate the title. Before animating the text for the “safety” pillar, ask the participants what questions they would ask the patient and his family about patient’s safety. Then, animate the text. Repeat this process for each of the following pillars: medical health, mental health and follow-up.
16. Show Slide 51: Case 1: Biopsychosocial Considerations.
Animate the title. Ask participants to take five minutes to fill out the biopsychosocial considerations table in their participant handbook for Case 1. Specifically have the partici-pants write what information they know, and what further considerations or information they would want to find out. Then, ask the participants to share their answers for the “bio” column, animating the column after all responses have been given. Ask the participants to share their answers for the “psycho” column, animating the column after all responses have been given. Repeat the same process for the “social” column.
17. Show Slide 52: Case 1: Resolution.
Ask a participant to read the slide. Ask the participants if they can appreciate how the four pillars of emergency management and the biopsychosocial approach were used to manage this case. Ask if there are any questions.
18. Ask the participants to take a moment to review the checklist again. Emphasize how the checklist draws upon these two approaches (four pillars of emergency management and biopsychosocial approach). Note how psychologists and social workers are responsible for completing the mental health evaluation while physicians are responsible for the medical management of patients.
19. Before finishing this session, show the participants the table in their participant handbook entitled “Four Pillars of Emergency Management of Agitation, Delirium and Psychosis.” Inform them that they can use this table as a reference tool.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 31
THE FOUR PILLARS OF EMERGENCY MANAGEMENT OF AGITATION, DELIRIUM, AND PSYCHOSIS
1. SAFETY
Violence:
• Is the patient agitated or violent currently? (Use the Agitated Patient Protocol)
• What is the history of violence? When did it happen, how severe was it?
• Is the patient being exposed to violence/abuse?
Suicide:
• Is the patient suicidal currently? Actively or passively?
• What is the history of suicide? Past attempts with medical severity, past suicidal ideation? When did it happen?
Management:
• How is safety being managed? Is 1:1 present?
• How is risk being decreased?
2. MEDICAL
Medical Evaluation of Psychosis:
• Must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, HIV and RPR for all patients; renal and hepatic panels if available; CD 4 count for all HIV patients).
• Consider a CT scan if the patient has a clear neurological deficit.
Consider Delirium:
• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.
• Treatment is aimed at underlying medical problem and avoiding diazepam.
Consider Epilepsy (Post-Ictal Psychosis):
• The family reports the development of psychosis/agitation after seizures.
• Treatment is anti-epileptic.
Medication Management:
• Use the medication card to dose and prescribe.
• Provide fluids and do an EKG for all hospitalized/emergency room patients receiving haloperidol.
• Check for medication side-effects; do AIMS.
• Check vital signs and weight for all patients
32 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. MENTAL HEALTH
Diagnosis:
• Work with a psychologist/social worker, use the Differential Diagnosis Information Sheet.
• Reconsider the diagnosis at each visit.
Psychoeducation and Support:
• Provide education to patients and families regarding psychosis and medication.
Medication Management:
• Use Medication Card for Agitation, Delirium and Psychosis; consider diagnosis.
4. FOLLOW-UP
Date of next appointment/visit:
• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.
• Involve community health workers in the care.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 33
DAY 1 REVIEW: Group Presentations
Methods: Group presentations
Time: 30 minutes
Materials: � Flip chart � Markers
STEPS
30 minutes
1. Explain to the participants that they will be reviewing yesterday’s sessions by participating in group presentations.
2. Tell the participants that they will be divided into small groups and will be assigned a session from yesterday. The groups will have 10 minutes to create a three to five minute presentation summarizing the most important information from their assigned session. Each group will be given a piece of flip chart paper and markers — participants are free to draw, create a map, or write an outline to present their information to the audience.
3. Divide the participants into three groups. Distribute the flip chart paper and markers. Assign one of the following sessions to each group (if there are more than five participants in each group, participants should be divided into further groups. You can assign the same session to more than one group):
• Session 2: Epidemiology, Stigma and the Treatment Gap
• Session 3: Diagnosis of Severe Mental Disorders
• Session 4: The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium and Psychosis
4. Read the following questions aloud to the participants to guide their work:
• What were some of the key points raised during the session?
• What ideas and suggestions are you taking away from this training?
5. After 10 minutes, invite each group to the front of the room to present. (If you have more than three groups, just invite one group per assigned session to present). Instruct the timer to time each group so that no group goes over the five minute time limit. Thank each group after they have presented.
34 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 5: Safety and Management of Agitated Patients
Methods: Facilitator presentation, role plays
Time: 2 hours
Participant Handbook page: 22
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 53 – 67 � Flip chart � Markers
Preparation:
• Review the PowerPoint (Agitation, Delirium, and Psychosis), slides 53 – 67.• Make copies of Suicidality Screening Instrument (1 copy/participant).• Facilitators should review and practice the role play.
Objectives:n. Describe the identification, triage, and non-pharmacological management of an agitated
patient through the use of the Agitated Patient Protocol, and Agitation, Delirium and Psychosis Form.
o. Explain how to screen for suicidal ideation and manage suicidal patients consistent with their severity and risk level.
STEPS
45 minutes
1. Show Slide 53: Session 5: Safety and Management of Agitated Patients.
Remind the participants that they learned about the four pillars of emergency management yesterday. Ask the participants what the first pillar is: safety! Explain that participants will spend this session learning about safety and management of agitated patients.
2. Ask the participants:
• Why it is important to be able to manage an agitated patient?
• What experiences do you have managing agitated patients?
Allow for a few participants to respond.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 35
3. Have the participants turn to the Medical Evaluation Protocols for Agitation, Delirium and Psychosis in their participant handbook. Explain that this protocol guides physicians from managing an agitated patient (Step 1a) to performing a medical assessment to rule out delirium (Step 2). Give the participants a minute to read over the protocol.
4. Show Slide 54: What is the first step in managing an agitated patient?
Animate the slide. Tell the participants that often physicians and other health providers are unsure what to do when there is an agitated patient. Ask the participants to show how they would answer the question by raising their hands:
• Who thinks the first step is A?
Pause for the participants to raise their hands. Continue by asking who would do B, C, and D as a first step.
Explain that the answer is D, and animate the slide. Tell the participants that talking to the patient allows you to evaluate the risk of violence, begin the medical evaluation, and calm the patient. The physician and psychologist/social worker should always attempt to talk to the patient before prescribing medication.
5. Show Slide 55. Managing Agitated Patients Following the Psychosis Care Pathway.
Emphasize to the participants that physicians manage agitated patients as a team with psychologists/social workers and nurses. Clarify that these roles listed on the PowerPoint slide are found on the Agitation, Delirium and Psychosis Checklist under “Agitated Patient” for each cadre.
6. Have the participants turn to the Agitated Patient Protocol, and Agitation, Delirium and Psychosis Form in their participant handbooks. Explain that these forms are the main tools that participants will use to evaluate and manage agitated patients. Specify that the Agitated Patient Protocol will assist participants in properly managing different levels of agitation. The Agitation, Delirium and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic. Give the participants several minutes to review the forms independently.
7. Show Slide 56: Agitation Etiology.
Animate the speech bubble. Ask participants the following question:
• By a show of hands, who thinks agitation is a disease?
Wait for participants to raise their hands.
• Who thinks agitation is not a disease?
Wait for participants to raise their hands. Respond by animating the text on the slide.
36 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
8. Show Slide 57: Agitation/Violence Spectrum.
Explain that there is a spectrum of agitation and patients can fall anywhere on the spectrum. Choose participants to read aloud the various behaviors of those with mild, moderate and severe agitation. Ask the participants to take a moment to look at the Agitated Patient Protocol. Ask participants if they see the different degrees of agitation/aggression/violence and that this level determines the management of the patient. Explain that the purpose of the Agitated Patient Protocol is to guide safe and effective care of patients, including reducing the use of physical restraint and medication.
9. Explain to the participants that there are some key differences in agitation management, especially in the treatment between moderate and severe agitation. Ask the following questions to provoke critical thinking and discussion. Pause between questions to allow participants to respond. Give additional information as needed.
• When should we give medication intramuscularly?
– From a human rights perspective, we always want the least restrictive approach and use the fewest interventions necessary. Physicians only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. Physicians only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.
• Why is it important that we monitor the vital signs of the patients to whom we give medication?
– The process of taking medication or having medication administered against one’s will can be stressful. Stress, in combination with medical and psychiatric conditions, can lead to physiological instability. The medications themselves can affect the heart, for example potentially causing heart arrhythmia. Vital signs are key measures to physiologic status and are therefore essential.
• In what situations should clinicians use physical restraint?
– From a human rights perspective, the goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:
• If calming measures have been tried AND
• The patient has been offered an oral medication and refused AND
• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND
• It is felt that all alternatives have been tried.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 37
• It is important for providers to learn from their experiences, and from each other. A “debrief” can be an important measure to take in the context of managing agitation. Physicians can take the lead in organizing a team debrief. When you organize the team and debrief with staff, what should you talk about?
– A brief summary of the event; what worked well; what didn’t work well; what should be done differently in the future; who is responsible for follow-up.
10. Show Slide 58: When Managing an Agitated Patient: Safety and Talking First.
Read the slide. Tell the participants that this safety information is on the Agitated Patient Protocol. Explain to the participants how to ensure safety and remind them it is the first of the four pillars of emergency management for a reason. Emphasize that a physician or nurse should never inject a patient with haloperidol without speaking to the patient first, even if the patient is agitated.
11. Have the participants turn to the Agitation, Delirium and Psychosis Form. Point out that the first box on the form is about safety. Explain the steps in completing the safety section of the form. Remind the participants that while physicians will be responsible for filling out this form psychologists/social workers should know what is on the form to help if needed.
30 minutes
12. Show Slide 59: Agitated Patient 1.
Have a participant read the case study aloud.
13. Tell the participants that the facilitators will now put on a three minute role play acting out this case.
INSTRUCTIONS FOR THE FACILITATOR
During this role play, one facilitator will play the part of a physician and the other will play the part of the patient. The facilitator playing the physician will demonstrate inappropriate, commonly-used tactics for managing agitated patients. In particular, the facilitator playing the role of the physician should raise his/her voice at the patient, threaten to inject the patient with medication and tie the patient up, demonstrate anger and frustration, and not provide any medical care (such as doing vital signs or a physical exam).
38 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
14. After the role play concludes, ask the participants: What went wrong? Allow them to respond and add any of the following points they may have missed.
• Raising one’s voice at the patient
• Threatening to tie up the patient/give an injection
• Showing anger and frustration
• Not providing care to the patient
15. Ask the participants to use the Agitated Patient Protocol to discuss how they would approach the patient instead. Allow them one minute to read over the Agitated Patient Protocol and then have the participants share their answers with the person sitting next to them. Ask for a few pairs to share their answers. Responses should include. emphasizing safety first, talking before injecting, and managing the behavior and the environment.
16. Show Slide 60: Gathering Information for Evaluation.
Animate the slide’s title. Explain to the participants that psychologists/social workers should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. Show the patients the top box of the Agitated Patient Protocol that says “Throughout Visit: Assessment.”
Then, ask the participants what questions they might ask the neighbors who brought the man to the health center in the case study. Ask for the participants to share their answers. Once all answers have been shared, animate the text on the slide. Mention that while it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible depending on the level of agitation.
17. Show Slide 61: Performing a Brief Assessment.
Remind the participants that throughout the process of interacting with the agitated patient, physicians and psychologists/social workers will be working together to perform assessments to understand if there is a medical illness or mental illness. Physicians will be doing the medical portion of assessments, while psychologists/social workers will be helping to obtain information about mental health history and suicide and violence risk.
18. Show Slide 62: Agitated Patient 2.
Tell the participants they will continue to practice their use of the Agitated Patient Protocol and the Agitation, Delirium and Psychosis Form through another three to five minute role play. Ask for five volunteers and assign each of them to one of the following roles. a patient, two family members, a physician, and a psychologist/social worker. The physician will be responsible for using Agitation, Delirium and Psychosis Form to properly manage and medically evaluate the patient. Both the psychologist/social worker and physician should use the Agitated Patient Protocol.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 39
After the role play has concluded, debrief with the audience. Ask the audience the following questions:
• What level of agitation did this patient have?
• What did the psychologist/social worker and physician do well?
• What could have been improved?
45 minutes
19. Tell the participants that another key part of safety includes the identification and triage of patients who may have suicidal ideation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality.
20. Explain to the participants that psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If it is not immediately apparent if the patient has a history of suicide attempts, but there is a concern about the patient’s self-harm (whether past or present), the psychologist/social worker should also administer the Suicidality Screening Instrument.
21. Have the participants open their participant handbook to the Suicidality Screening Instrument. Explain that psychologists/social workers will use the Suicidality Screening Instrument to determine the severity of suicidal ideation depending on the answers of the patient. Give the participants one to two minutes to read over the screening instrument.
22. Tell the participants that they will ask the six questions on the Suicidality Screening Instrument in order, and for each question the psychologist/social worker will inquire whether the patient had those thoughts in the past two weeks and/or in the past year. The psychologist/social worker will check the answer that the patient gives for each question (yes or no). If the patient gives details or information during the screening, it should be written down in the appropriate “description” space. If a patient says no to a question in both columns, the interview ends there and should not continue (because each question builds on the one before it, assuming “yes” was indicated).
23. Explain when the psychologist/social worker has finished asking the questions (or has received a no for both columns, ending the interview), the psychologist/social worker will add up the number of “yes” in each column and write the total number of “yes” for each column on the scoring line. Then, the participants will look at the scoring criteria below and determine the risk depending on the scores for the current column and the past column.
40 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
24. Tell the participants they will now have the opportunity to practice screening for suicidality through two guided role plays (refer to Facilitator Notes). Ask the participants to turn to the role plays in their participant handbook. Explain that the participants will be split into pairs, and one person will play the psychologist/social worker, while the other will play the patient. The participants will have three minutes to complete Role Play #1, following the script in the participant handbook. Once the role play is complete, the psychologist/social worker role will have the responsibility of scoring the interview.
25. Divide the participants up into pairs, have each pair choose who will play each role, and have all pairs begin Role Play #1. After the participants have finished the role play (it should take no more than three minutes), remind the psychologist/social worker role to record his score on the sample screening instrument in his participant handbook.
26. Tell the participants that now, staying in their pairs, they will switch roles and conduct Role Play #2.
27. After the participants have finished the role play (it should take no more than three minutes), remind the psychologist/social worker role to record his score on the sample screening instrument in his participant handbook. Bring all the participants back together.
28. Show Slide 63: Determining Suicide Risk: Scoring of Screening Instrument.
Animate the title. Ask the participants who were the psychologists/social workers in Role Play #1 what score they determined. Take a few answers from the participants. Animate the slide text. Tell them the correct scoring is:
• Now/In Past 2 Weeks = 0
• In Past Year = 2
Go over any questions if participants determined a different score.
Ask the participants who were the psychologists/social workers in Role Play #2 what score they determined. Take a few answers from participants. Animate the slide text. Tell them the correct scoring is:
• Now/In Past 2 Weeks = 3
• In Past Year = 3
Go over any questions if participants determined a different score.
29. Tell the participants that once they have a score from the Suicidality Screening Instrument, they will determine a category of risk. As the participants see, there are different categories of risk that span from low risk to high risk. Tell the participants it is important to determine the category of risk so the psychologists/social workers can properly use the Suicidality Treatment Guidelines. The level of risk takes into account both the scoring from the questions “now or in the past two weeks” and “in the past year.”
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 41
30. Ask the participants to use the scores for the past two role plays to determine the level of risk of each of those patients.
• Ask: What would the participants label “Emmanuel” (Role Play #1 patient)?
Wait for participants to give answers. Confirm that he would be “medium risk.”
• Ask: What would the participants label “Katrina” (Role Play #2 patient)?
Wait for participants to give answers. Confirm that she would be probably “high risk” because she has a current score of three, a past score of three, and indicated she might act on her suicidal thoughts.
31. Explain that once a level of risk is determined, psychologists/social workers will use the Suicidality Treatment Guidelines to treat the patient accordingly. Have the participants look at the Suicidality Treatment Guidelines in their participant workbook. Explain that the chart walks the participants thought the things they should do, say, refer to, record and follow up with in terms of treatment for the patient. All patients, including the patients with low risk, should receive the treatment in the first box, “for all patients.” If a patient has a medium or high risk, they should pass to the second box, “for patients with medium and high risk” which has additional treatment aspects. If a patient is high risk, they should also receive treatment in the third box, “for patients with high risk.”
32. Tell participants to look at the first box on the Treatment Guidelines under “for all patients” that says “act.” The participants will see that point number three refers to developing a safety plan. Tell participants that all patients who are screened for suicidality, whether low risk or high risk, need a safety plan. A safety plan is a plan, collaboratively developed by the patient and psychologist/social worker, which assists patients to decrease their risk of suicide. Have the participants turn to the Safety Plan in the annex of their participant handbook.
33. Show Slide 64: Suicidality: Safety Plan.
Explain that psychologists/social workers will go through creating a plan with the patient that will outline how the patient will recognize when they are in a crisis, and how to prevent suicide through five distinct steps (if one step fails to decrease the level of suicide risk, the next consecutive step is followed).
34. Show Slides 65 – 66: Safety Plan Instructions.
Have a participant read through the steps on the slide that outline the components of a safety plan. Remind the participants that their role as psychologist/social worker is to support patients in creating this plan (the psychologists/social worker is not creating this plan for the patients!).
42 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
35. Show Slide 67: Considerations When Creating a Safety Plan.
Read the points on the slide and emphasize that the most important aspect of the safety plan is its accessibility and ease of use. A safety plan will not be helpful if there are obstacles in the plan that the patient cannot overcome. The psychologist’s /social worker’s role is to discuss feasibility of the plan’s steps with the patient so the patient is prepared. Ask if there are any questions about the Safety Plan.
36. Conclude the session by reminding the participants that safety is the first pillar of emergency management. Talking to a patient effectively and helping the patient to feel safe and respected — not simply medicating a patient — is a key part of safety and evaluation.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 43
FACILITATOR NOTES
ROLE PLAY 1
Psychologist/Social Worker: Hello Emmanuel.
Patient: Hello.
Psychologist/Social Worker: I’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the health facility is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that I would like to be helpful to you.
Patient: OK.
Psychologist/Social Worker: Sometimes, when things are particularly difficult, some people have thoughts of not wanting to live. Have you ever wished you were dead in the past two weeks?
Patient: No.
Psychologist/Social Worker: Have you ever wished you were dead in the past year?
Patient: Yes.
Interview continues because patient said yes.
Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past two weeks?
Patient: No.
Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past year?
Patient: Yes. Things were just so hard!
Interview continues because patient said yes.
Psychologist/Social Worker: Have you been thinking of ways to do this in the past two weeks?
Patient: No.
Psychologist/Social Worker: Have you been thinking of ways to do this in the past year?
Patient: No. I never decided to do anything.
Interview ends because patient said no to each column of a question.
44 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
ROLE PLAY 2
Psychologist/Social Worker: Hello Katrina.
Patient: Hello.
Psychologist/Social Worker: I’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the hospital/clinic is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that I would like to be helpful to you.
Patient: OK.
Psychologist/Social Worker: Have you ever wished you were dead in the past two weeks?
Patient: Yes.
Psychologist/Social Worker: Have you ever wished you were dead in the past year?
Patient: Yes.
Interview continues because patient said yes.
Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past two weeks?
Patient: Yes. I don’t want to live anymore, but I know my family would feel so bad.
Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past 12 months?
Patient: (Nods).
Interview continues because patient said yes.
Psychologist/Social Worker: Have you been thinking of ways to do this, now or in the past two weeks?
Patient: Yes, I think a lot about it.
Psychologist/Social Worker: Have you been thinking of ways to do this, in the past year?
Patient: Yes, I guess I’ve been thinking about it for a long time.
Interview continues because patient said yes.
Psychologist/Social Worker: Do you have any intention to act on these thoughts?
Patient: I’m not sure…
Psychologist/Social Worker: We are here to help you, you are not alone. I would like to work with you to develop a plan to support you given that things are so difficult currently.
Interview ends as clinician develops a plan to support the patient based on the rest of the history obtained.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 45
SESSION 6: Medical Evaluation and the Management of Agitation, Delirium, and Psychosis
Methods: Facilitator presentation
Time: 30 minutes
Participant Handbook page: 28
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 68 – 78 � Flip chart
� Markers � Tape
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 68 – 78.
Objectives:p. Define medical delirium.q. Describe the importance of proper medical evaluation for an agitated, delirious or
psychotic patient.r. Explain the process of carrying out a medical evaluation for an agitated, delirious
or psychotic patient.
STEPS
45 minutes
1. Show Slide 68: Session 6: Medical Evaluation and Management.
Tell the participants that once they have calmed an agitated patient, the team of clinicians will need to determine if the patient is psychotic or has a medical delirium.
2. Show Slides 69 – 70: Case- Part 1 and Case – Part 2.
Review the case by having a participant read the case aloud. Allow the participants to indicate whether they agree or disagree with the management of the case and why.
46 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. Show Slide 71: Case – Part 3.
Ask the participants what went wrong. Give them time to respond. Highlight the points below:
• The patient did not receive a comprehensive medical evaluation.
• Haloperidol was used inappropriately and dangerously to sedate the patient (using haldoperidol to sedate patients can kill them!).
• The patient was not properly diagnosed with delirium (psychosis and agitation are medical problems until proven otherwise).
4. Show Slide 72: Consequences of Mismanagement of Agitation, Psychosis and Delirium.
Walk the participants through the case timeline on the PowerPoint slide, highlighting the consequences of sedating a patient rather than doing a medical evaluation that would have uncovered a medical delirium (not psychosis).
5. Show Slide 73: Definition of Agitation, Delirium and Psychosis.
Read through the definitions. Emphasize how all of these phenomena are considered medical problems unless proven otherwise; these patients are not automatically “mental health patients,” rather they are medical patients who need care from physicians.
6. Show Slide 74: Definition of Delirium.
Tell the participants that delirium is not well understood biologically, but that it can be understood as a physiological imbalance in the body and brain that can be potentially fatal. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses. Remind the participants of the case of the 28-year-old woman who was seven months pregnant and died.
7. Show Slide 75: Physical Illness Causes Delirium.
Ask the participants:
• Which physical illnesses cause delirium?
Read the list of medical problems and indicate which ones are common in Haiti.
8. Show Slide 76: Other Medical Causes of Psychosis/Agitation.
Read the slide.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 47
9. Show Slide 77: Standard Medical Evaluation for Delirium/Psychosis/Agitation.
Ask the participants:
• How would you medically evaluate patients to determine whether a medical problem is the cause of their agitated or psychotic behavior?
Once the participants have responded, animate the answers on the slide. Remind the par-ticipants that the physician will be performing the medical evaluation, but it is important for psychologists/social workers to understand what physicians will be doing.
10. Have the participants turn to the Medical Evaluation Protocols for Agitation, Delirium and Psychosis in their participant handbooks. Remind the participants that they saw this protocol last session, and were focused on the managing agitation portion (Steps 1a and 1b). Now, they can use this protocol (Step 2) to assist the physician in managing the medical assessment portion. Read aloud the steps of the medical assessment as described by the protocol. Emphasize that a mental health problem cannot be considered until the physician has completed this entire medical protocol and has established whether the patient does or does not have a medical delirium.
11. Show Slide 78: How do you distinguish between mental illness and medical illness?
Animate the title. Allow the participants to look at the Medical Evaluation Protocols for Agitation, Delirium and Psychosis and then respond with their ideas. Then, animate the text.
48 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 7: Biopsychosocial Clinical Formulation
Methods: Facilitator presentation, case studies
Time: 1 hour 30 minutes
Participant Handbook page: 30
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 79 – 93 � Flip chart
� Markers � Tape
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 79 – 93.
Objectives:s. Explain how to gather information for a complete mental health history.t. Describe how to create a biopsychosocial clinical formulation to guide a patient’s treatment.
STEPS
1 hour
1. Show Slide 79: Session 7: Biopsychosocial Clinical Formulation.
Tell the participants that, if after a medical evaluation, it has been concluded that a patient has a mental illness, the psychologist/social worker will complete the Initial Mental Health Evaluation Form. This includes recording a complete mental health history and creating a biopsychosocial clinical formulation for a patient.
2. Show Slide 80: Information to Obtain from Patient/Family.
Explain to the participants that during the management of an agitated patient, there may have been some mental health history taken and recorded on the Agitated Patient Form. However, once a medical illness has been ruled out and the patient is no longer agitated, it is very important for the psychologist/social worker to obtain a complete mental health history to inform diagnosis and clinical formulation.
3. Show Slide 81: General Principles for Evaluating Patients with Mental Disorders.
Tell the participants that these are basic principles that they already have learned, but should review.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 49
4. Show Slide 82: Conducting a Complete Mental Health History.
Animate the three questions on the slide. Tell the participants that they will take the next three minutes to brainstorm the answers to the questions on the slide with the person sitting next to them. Once three minutes has elapsed, ask the participants to share their responses.
5. Show Slides 83 – 84: Questions to Ask to Obtain History.
After the participants have shared their answers, animate the text. Explain that it is crucial to obtain details regarding illness progression, impact on overall functioning and family history. Clarify what questions psychologists/social workers should ask to obtain mental health history. Ask the participants if they notice that these different pieces of history comprise a biopsychosocial history.
6. Emphasize that the Initial Mental Health Evaluation Form has specific sections to record each of type of history, which includes “History of Present Illness,” “Past Psychiatric History,” “Past Medical History,” “Psychiatric Family History.”
7. Show Slide 85: Start General Then Be Specific.
Explain that psychologists /social workers should always start their conversations with open-ended questions and then probe with specific questions when they hear about a certain illness or symptoms. Psychologists/social workers should always try and speak to the family or someone who knows what has been occuring. Ask the patient’s permission before you do this. While it is very important to hear what is going on from family members, it is also important that the patient has the chance to speak. Remember it is up to the psychologist/social worker to decide if a person has a mental illness, not the person’s family. If the person is not allowed to speak or not given enough time to answer questions by their family, you may miss important symptoms. You may also wrongly diagnose a mental illness when a person is in fact healthy!
Do not correct the patient if the patient says things that are strange or unbelievable. Do not agree with them either. Make sure they have understood the question you have asked and let them know that you have listened to their response. An example would be to say: “Thank you for telling me that. I am grateful you could be so honest. I guess there are a lot of different ways of looking at the world.”
8. Show Slide 86: Utilize the Systematic Interview Technique.
Tell the participants that once they receive information about a patient’s symptoms, they should use the systematic interview technique to help identify what mental disorder a patient may or may not have. The psychologists/social workers should use the Differential Diagnosis Information Sheet to guide their questions about symptoms for specific disorders.
50 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
9. Show Slide 87: Additional Questions to Guide the Mental Health Evaluation.
Read the questions aloud to the participants.
10. Show Slide 88: After Trust has Developed, Further Assess Safety and Stressors.
Tell the participants that they should assess the safety of the patient through asking the questions listed on the slide.
11. Show Slide 89: Biopsychosocial Clinical Formulation.
Animate the title and speech bubble. Ask the participants who has made a clinical formu-lation before and what a clinical formulation is. Wait for a few responses and then animate the text.
Tell the participants that a clinical formulation is not a summary of the clinical data. A formulation must contain a theory about the etiology of the patient’s problems, related developmental status and strengths.
12. Show Slide 90: Importance of Clinical Formulation.
Animate the title and speech bubble and ask why a clinical formulation is important. Wait for a few responses and then animate the text.
13. Show Slide 91: Creating a Biopsychosocial Formulation.
Read the points on the slide. This clinical formulation will be recorded on the Initial Mental Health Evaluation Form on page 4.
14. Instruct the participants to look at the example of the biopsychosocial clinical formulation in their participant handbook. Have all participants take two minutes to silently read the example in their participant handbook. Ask if there are any questions.
BIOPSYCHOSOCIAL CLINICAL FORMULATION EXAMPLE
Peterson is a 21-year-old male living in Mirebalais who lives with his parents and presented to the hospital with a chief complaint of “hearing voices.” From a biological perspective there is a family history of a similar problem (his father), and he also experienced head trauma in a motorcycle accident several years ago. From a psychological perspective, Peterson has experienced significant shame about his illness, which has significantly affected his self-esteem. He and his family believe that these symptoms are related to a curse that was cast on the family. From a social perspective, they also are poor, Peterson’s father drinks alcohol excessively, and at times there is domestic violence. Peterson has strengths in that he has been a good student at school, he goes to church, and he participates in a musical group.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 51
15. Have the participants look at the table in their participant handbook that outlines how to document a clinical formulation from a biopsychosocial perspective (refer to Facilitator Notes). Tell the participants they can use this table’s wording to help them create a clinical formulation. Read through the table with the participants.
30 minutes
16. Tell the participants they will practice formulating a biopsychosocial clinical formulation using case studies (refer to Facilitator Notes).
17. Ask the participants to turn to the biopsychosocial formulation cases in their participant handbooks. Tell the participants that they will spend 15 minutes individually creating biopsychosocial formulations for two cases.
18. After 15 minutes, choose a few participants to present their answers for Case #1.
• Show Slide 92: Case #1.
Explain to the participants that the clinical formulation on the slide is a sample formula-tion. Emphasize that biological, psychological, social and strengths perspectives should always be present in a biopsychosocial formulation.
19. Choose 1 – 2 participants to present their answers for Case #2.
• Show Slide 93: Case #2.
Explain to the participants that the clinical formulation on the slide is a sample formulation.
Emphasize that biological, psychological, social and strengths perspectives should always be present in a biopsychosocial formulation.
52 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTESB
IOP
SY
CH
OS
OC
IAL
CL
INIC
AL
FO
RM
UL
AT
ION
TA
BL
E
Bio
logi
cal
Psyc
holo
gica
lSo
cial
Stre
ngth
s
Ther
e ap
pear
to
be n
o si
gnifi
cant
bi
olog
ic f
acto
rs in
the
pat
ient
’s cu
rren
t pr
esen
tatio
n.
OR
Ther
e ar
e se
vera
l bio
logi
c co
nsid
erat
ions
in a
sses
sing
the
pa
tient
’s cu
rren
t pr
esen
tatio
n.
Thes
e in
clud
e:
• a
deve
lopm
enta
l his
tory
no
tabl
e fo
r __
_.
• a
hist
ory
of s
ubst
ance
abu
se•
a fa
mily
his
tory
of
__ a
nd a
po
tent
ial p
redi
spos
ition
to
illne
ss•
a hi
stor
y of
hea
d tr
aum
a,
seiz
ures
, or
infe
ctio
n•
ster
eoty
pies
not
able
on
exam
th
at m
ight
indi
cate
pot
entia
l ps
ychi
atric
co-
mor
bidi
ties
• de
velo
pmen
tal d
isab
ilitie
s or
se
rious
dev
elop
men
tal fi
ndin
gs•
a hi
stor
y of
med
icat
ion
side
- ef
fect
s•
co-m
orbi
d m
edic
al il
lnes
s,
and
diffi
culty
cop
ing
with
tha
t ill
ness
From
a g
ener
al p
sych
olog
ical
pe
rspe
ctiv
e, X
YZ
desc
ribes
his
/he
r cl
oses
t re
latio
nshi
ps t
o be
__
. He/
she
lives
wit.
__
and
the
natu
re o
f th
ese
rela
tions
hips
is
__.
Ther
e ar
e se
vera
l psy
chol
ogic
al
cons
ider
atio
ns in
ass
essi
ng t
he
patie
nt’s
curr
ent
pres
enta
tion.
Th
ese
incl
ude:
• a
hist
ory
of p
erso
nal a
nd
fam
ily lo
sses
not
able
for
__
_.
• a
hist
ory
of in
terp
erso
nal
confl
icts
not
able
for
___
.•
a hi
stor
y of
inte
rnal
con
flict
ab
out
__.
• a
hist
ory
of c
halle
nges
re
gard
ing
__.
• be
lief
syst
em w
ith r
egar
ds
to m
enta
l hea
lth a
nd il
lnes
s
Thes
e ha
ve a
ffec
ted
the
pers
on
in t
he f
ollo
win
g w
ays:
__.
From
a s
ocia
l per
spec
tive,
ar
eas
of c
once
rn in
clud
e __
_.
Ther
e ar
e se
vera
l soc
ial
cons
ider
atio
ns in
ass
essi
ng t
he
patie
nt’s
curr
ent
pres
enta
tion.
Th
ese
incl
ude:
• fa
mily
/liv
ing
situ
atio
n,
spec
ifica
lly _
_.•
wor
k, s
peci
fical
ly _
_.•
finan
cial
/eco
nom
ic,
spec
ifica
lly _
_.•
rece
nt c
hang
es a
nd
tran
sitio
ns o
f no
te s
uch
as _
_.•
high
ris
k be
havi
ors
such
as
sexu
al o
r be
havi
oral
• hi
gh e
nviro
nmen
tal
risk
such
as
dom
estic
vi
olen
ce o
r be
ing
harm
ed
or t
hrea
tene
d at
hom
e,
scho
ol, w
ork
or in
the
co
mm
unity
Are
as o
f si
gnifi
cant
st
reng
th, c
ompe
tenc
y an
d m
aste
ry
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 53
BIOPSYCHOSOCIAL FORMULATION CASES
CASE 1
A 22-year-old woman, Darline, is brought in by her husband to the health facility in Cange. He says that his wife has been acting strangely. He reports that she has refused to get out of bed for the past week and has been crying frequently. Darline is usually very active in church but hasn’t gone the past two weeks. He was worried she was depressed. However, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe Darline chatting excitedly with other people in the waiting room. She says she feels wonderful and doesn’t know why her husband brought her here. When you ask Darline if there is any family history of mental illness she declines to reply. She asks you angrily what you are trying to suggest. She says that nothing is wrong with her, although she does admit she was feeling sad last week. The husband mentions that he is worried and frustrated because she hasn’t been able to work as much the past two weeks because of her condition, and that it’s straining the family finances. When asked about her physical health, Darline states she has no health problems. Her husband reports that this is the first time that Darline has acted this way.
Biopsychosocial formulation: (To be filled in by participant)
Darline is a 22-year-old female living in Cange with her husband. Her husband brought her to the hospital with a chief complaint of depression and “acting strangely.” The patient did not answer when asked if there is a family history of mental illness, but from a biological perspective it is possible that the current situation represents a manic episode. It does not appear that there was a recent stressor that may have made things worse, but it does appear that her condition is causing significant stress to the family and there is risk of lost productivity and greater financial stress from her inability to work effectively. From a general psychological perspective, Darline does not seem to have insight into her mood swings. She describes everything is fine, although she admits she was depressed last week. From a social perspective, areas of concern include her relationship with her husband, who is worried and frustrated about Darline’s behavior, and is unable to work because of it. Darline has strengths in her connection to the church and the support of her husband. Of primary concern currently is the possibility that this episode is a manic episode consistent with bipolar disorder, which places both Darline and her family at risk on multiple levels. Further history and observation will help in clarifying the diagnosis. In the meantime the treatment team will focus on treating this as a manic episode and will work to stabilize the situation in collaboration with her and her family.
54 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
BIOPSYCHOSOCIAL FORMULATION CASES (continued)
CASE 2
A 20-year-old man, James, is brought in by his friend, Simon. Simon says that recently James started saying that his neighbor is watching him; James cannot stop talking about it. James thinks that the neighbor is a spy. James lives with his aunt and used to go to school. James was a good student, but he stopped going to school because he couldn’t concentrate. James reports that he hears what the neighbor is saying about him in his mind. The neighbor says “I’m watching you. I’m going to get you.” When you ask how long this has been happening for, James says almost three months. James is so scared that he can’t sleep at night. When you ask about his family history, James says he has never met his father, and he hasn’t seen his mother since she was hospitalized at Mars and Kline in 2011. Simon reports that James’ girlfriend broke up with James because she was scared of how James was acting. James has begun to use alcohol to relax because he is nervous all the time about his neighbor.
Biopsychosocial formulation: (To be filled in by participant)
James is a 20-year-old male who was brought to the health facility by a friend. James lives with his aunt (his parents are not around) and reports that his neighbor is spying on him. James can hear the neighbor’s voice in his head. From a biological perspective, there is a family history of mental illness (his mother), who has been hospitalized. From a psychological perspective, James is feeling very worried and scared about his neighbor. It would be helpful to know more about the relationship he has with his neighbor and if there were previous problems. He is unable to sleep at night and cannot focus on other things. There are several social considerations in assessing the patient’s current presentation, which include: James recently losing his girlfriend and missing school. He is using alcohol to cope with these losses. James’ strengths are his intelligence and social supports including his friend Simon. Given the biological vulnerability and the family history, the current situation is concerning for a first psychotic episode. Further history and observation will help in clarifying the diagnosis. In the meantime the treatment team will focus on treating this as a first episode and will work to stabilize the situation in collaboration with James and his family.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 55
SESSION 8: Medication Management for Agitation, Delirium, and Psychosis
Methods: Facilitator presentation, worksheet, role play
Time: 2 hours
Participant Handbook page: 36
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 94 – 109 � Medication Card for Agitation,
Delirium and Psychosis
� Flip chart � Markers
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 94 – 109.
Objectives:u. Explain the collaboration between the physician and the psychologist/social worker in
managing medication for agitation, delirium and psychosis.v. Describe the physician’s use of the Medication Card for Agitation, Delirium and
Psychosis.
STEPS
30 minutes
1. Show Slide 94: Session 8: Medication Management for Agitation, Delirium and Psychosis.
Tell the participants that once a medical and mental health evaluation has been performed, a physician must decide if pharmacological treatment is necessary.
2. Show Slide 95: Zanmi Lasante Tools for Prescribing Psychotropic and Anti-Epileptic Medications.
Briefly review the primary tools that can be used to guide physicians’ prescribing practices. After you illuminate the bullet point “Medication Card for Agitation, Delirium, and Psychosis” on the PowerPoint, give the participants five minutes to review the medication card independently.
56 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. Show Slide 96: Review of Zanmi Lasante Formulary.
Animate the title and speech bubble. Ask the participants what medication for mental disorders they can name. Animate the table.
4. Show Slide 97: Risperidone.
Read the important points outlined on the slide. Mention to the participants that this medication should be the first-choice drug for any patient that needs an antipsychotic or mood stabilizer.
5. Show Slide 98: Haloperidol.
Read the important points outlined on the slide. Emphasize that risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggres-sive and could benefit from the sedation of haloperidol.
6. Show Slide 99: Carbamazepine.
Read the important points outlined on the slide. Emphasize that carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.
7. Show Slide 100: Valproate.
Read the important points outlined on the slide. Emphasize that valproate is particularly for patients with longstanding aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).
8. Show Slide 101: Diazepam.
Read the important points outlined on the slide. Emphasize that diazepam is only used in agitated patients and those going through alcohol withdrawal.
9. Show Slide 102: Anti-Psychotics: Side-Effects.
Explain to the participants that while physicians will need to evaluate and manage anti-psychotic medication side-effects, it is important that psychologists/social workers know about side-effects.
Read the text on the slide, emphasizing that acute dystonia and neuroleptic malignant syndrome are two side-effects that constitute an emergency. Tell the participants that tar-dive dyskinesia is a possible side-effect of antipsychotic medications, particularly “typical” antipsychotics such as haloperidol. Patients and their families need to know about these side-effects. Explain to the participants that lactation and missed periods for women are a side-effect from risperidone commonly encountered in Haiti.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 57
10. Show Slide 103: Prescribing Principles for Agitation, Delirium, and Psychosis.
Note that physicians should only prescribe risperidone and haloperidol. Mood stabilizers should not be routinely prescribed for bipolar disorder. Explain that if physicians prescribe more than the maximum dose of a medication to a client, the Zanmi Lasante Mental Health team must be notified.
11. Show Slide 104: Physician and Psychologist/Social Worker Collaboration.
Explain that physicians are responsible for prescribing antipsychotics but they must work with psychologists/social workers to determine the likely diagnosis. For physicians, identi-fying a medical delirium rather than a mental illness is the most important diagnosis that they can make. It can be life-saving. It is also important to note that physicians should not make diagnoses of specific psychiatric illnesses such as schizophrenia or bipolar disorder without the collaboration of a psychologist/social worker and the Zanmi Lasante Mental Health Team. This is because once a wrong diagnosis is made, a person may not only be labeled with the diagnosis, but also the stigma that can accompany a diagnosis. Wrong diagnosis can also lead to poor care for the patient, including prescription of the wrong medication. All patients who receive antipsychotics (for agitation, delirium, or psychosis) must be evaluated by Zanmi Lasante psychologists/social workers.
12. Show Slide 105: Physician Responsibilities for Anti-Psychotic Medication.
Ask the participants to take out their Agitation, Delirium and Psychosis Checklist and to review the physician sections (specifically the Initial Evaluation and Follow-Up sections). Ask them to focus on identifying their roles related to medication management. After a few minutes, have the participants share their answers with the person sitting next to them. After two minutes, animate the slide to show the Agitation, Delirium and Psychosis Checklist with physicians’ roles related to medication management in red.
20 minutes
13. Tell the participants that they will now take time to review information about medication for agitation, delirium and psychosis. They will have 10 minutes to complete the medication review questions in their participant handbook. Explain that they may use the Medication Card and Agitated Patient Protocol (refer to Facilitator Notes).
14. After 10 minutes, bring the participants together and go over the answers on the medication review sheet, asking for the participants to share their answers (refer to Facilitator Notes).
58 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
20 minutes
15. Show Slide 106: Psychoeducation about Medication.
Animate the title. Ask the participants:
• If you or a family member were being prescribed an antipsychotic, what information would you like to know about the medication?
Once some participants have responded, animate the text. Explain that it is important to speak to patients and their family members in language that they understand, depending on their education level and knowledge.
Mention additional information about prescribing principles:
• It is important to take the medication regularly and not miss a dose.
• Do not double up on a dose if a dose is missed.
• It is important to continue to take medication even if symptoms improve.
• Symptoms may worsen if medication is discontinued.
• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.
16. Show Slide 107: Psychoeducation – Case 1.
Ask a participant to read the case on the slide aloud. Give the participants one minute to consult the Medication Card for Agitation, Delirium and Psychosis, and ask for responses.
• What the medication is for: used for psychosis.
• How to take the medication properly: take it at night before bed because it can make you sleepy.
• Common side effects: sedation, weight gain.
• Toxic side-effects and when to seek immediate medical care: difficulty breathing, muscle tightness in body, difficulty seeing or controlling eyes (dystonia, tardive dyskinesia, akathisia), rash, hot feeling or fever, abnormal blood sugars (diabetes).
• How long it takes for the medication to work: It can work within one day. But for the full effect it takes 4 – 6 weeks.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 59
17. Show Slide 108: Psychoeducation – Case 2.
• What the medication is for: used for psychosis, especially in violent patients.
• Common side-effects: sedation, stiffness, a heavy tongue.
• Toxic side-effects and when to seek immediate medical care: difficulty breathing, muscle tightness in body, difficulty seeing or controlling eyes (dystonia, tardive dyskinesia, akathisia), rash, hot feeling or fever, abnormal blood sugars (diabetes).
• How long it takes for medication to work: Immediately. Once it has been given, the physician will wait 30 minutes and if patient remains agitated we can give haloperidol again (but only half the original dose).
18. Show Slide 109: Side-Effects – AIMS.
Read the slide and tell the participants that physicians will be utilizing the AIMS (Abnormal Involuntary Movement Scale) every six months with patients that are on an anti-psychotic medication. Explain to the participants:
• Tardive dyskinesia can develop over the course of months and years, and should be monitored using AIMS. AIMS is useful for detection and follow-up of tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.
• The AIMS should be used 1) at the beginning of treatment, and then 2) every six months. It can be done in less than 10 minutes.
60 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTES
MEDICATION REVIEW WORKSHEET
Use the Medication Card for Agitation, Delirium and Psychosis, and the Agitated Patient Protocol.
1. Which three medications on the medication card can Zanmi Lasante physicians prescribe without consulting the mental health team?
• Haloperidol
• Risperidone
• Diazepam
2. Which two medications on the medication card should NOT be routinely prescribed by Zanmi Lasante physicians for bipolar disorder or other forms of mental illness?
• Carbamazepine
• Valproic Acid
3a. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. What level of agitation does he have (mild, moderate, or severe)?
• Severe (violent)
3b. According to the Agitated Patient Protocol, which medication should the physician give the patient? Give the medication name, dose, and form.
• Haldol 5 –10 mg IM + diphenhydramine 25 mg IM or diazepam 10 mg IM
4. You are working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. She is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a break-up with her boyfriend. At the facility, she was given multiple injections. How would you work with the physician to treat this case?
• The patient has severe dystonia, and, therefore, should be given diphenhydramine 50 – 75 mg IM daily. The patient should receive liters of fluids to flush out the haloperidol and because she is receiving a strong dose of an anti-cholinergic medication. She should also be monitored closely for signs of neuroleptic malignant syndrome.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 61
DAY 2 REVIEW: Jeopardy
Methods: Game
Time: 1 hour
Materials: � PowerPoint (Jeopardy) � PowerPoint (Agitation, Delirium,
and Psychosis), slides 110 – 111
� Flip chart � Markers
Preparation:• Review PowerPoint (Jeopardy)
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 110 – 111.• Delegate the various game roles to the co-facilitators
STEPS
1 hour
1. Explain that the participants will now review the content that was just presented using a game called Jeopardy. Jeopardy is a question-and-answer type of game where participants can earn points by answering questions correctly.
2. Show Slide 110: Jeopardy Rules.
Explain that the first row on the slide shows the categories. Each question under that category column is related to that category.
3. Explain that each category will have a series of values listed under the category title. Each value corresponds to a different question. The questions with a greater value are more difficult questions. For example, a question with a value of 100 is easier than a question with 300 points. The value also corresponds to the points that are awarded for a correct answer.
4. Divide the participants into two or three groups according to the total number of participants (ideally, about five to seven participants per group). Tell the teams that they should decide on a team name and a team leader. The team leader will speak for the team.
62 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
5. To begin the game, the facilitator will ask the first team to choose a category and a value. The facilitator will read the question that corresponds to the category and value aloud. For this activity, one of the facilitators will keep score on a flip chart. Another facilitator should lead the game. A third presenter can be the “time-keeper” to monitor the elapsed time.
6. Show Slide 111: Jeopardy Rules.
Explain that the team leaders are responsible for raising their hand once their team thinks that they know the correct answer. The facilitator will watch carefully and will decide which team leader raised his or her hand first. The team whose team leader raised his or her hand first is given the first opportunity to try to respond to the question.
7. Each team has 30 seconds in which to answer the question that they are asked. If they answer incorrectly, the next team has an opportunity to answer correctly and so on. The team that answers correctly is awarded the points AND has the opportunity to choose the next category and value.
8. As play continues, questions about the training content often arise. Use the game to clarify information and answer questions that the participants may have.
9. Start the game, have fun, alter the rules as necessary, and reward the team who wins in the end!
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 63
SESSION 9: Psychotherapy and Family and Patient Education
Methods: Large group discussion, case study
Time: 1 hour 15 minutes
Participant Handbook page: 40
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 112 – 119 � Flip chart � Markers
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 112 – 119.
Objectives:w. Explain the core psychotherapy approaches for patients with severe mental illness.x. Describe how to educate patients and family members about the effects and
management of psychosis and bipolar disorders.
STEPS
20 minutes
1. Show Slide 112: Session 9: Psychotherapy and Family & Patient Education.
Read the objectives and introduce the session.
2. Show Slide 113: Vulnerability/Stress Model – Severe Mental Illness.
• Animate the title and speech bubble.
Ask the participants:
• What makes a patient with a severe mental illness more symptomatic?
Take a few responses from the participants, and animate the text on the slide.
64 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. Show Slide 114: Psychotherapy Approaches.
• Animate the title and speech bubble.
Ask the participants:
• What type of psychotherapy have you used in the past with patients who were psychotic or had severe mental illness?
Take a few responses from the participants, and animate the text on the slide.
Remind the participants that there are a variety of approaches for treating mental illnesses, many of which can be useful for treating patients with severe mental illness, like psychosis or bipolar disorder.
4. Show Slide 115: Considerations in Choosing a Therapy.
• Animate the title and speech bubble.
Ask the participants:
• For those of you who have used therapy with severe mentally ill patients, how did you decide what type of therapy to use?
Take responses from the participants, and animate the text on the slide.
5. Mention that a patient’s barriers are a large consideration in deciding what approach may work best. Ask participants what some patient barriers to receiving psychotherapy treatment may be, and mention the following barriers if not mentioned by participants:
• Caretaking responsibilities
• Financial limitations of patient and family
• Travel to clinic
• Family/peers are against treatment
• Cognitive limitations
• Immaturity
• Personality or psychopathological factors
6. Show Slide 116: Supportive Therapy.
Tell the participants this is a type of therapy that works well for those suffering from severe mental illness. Read the main points on the slide aloud.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 65
7. Show Slide 117: Interpersonal Therapy.
Remind the patients that they have already been doing interpersonal therapy with patients with depression. Explain that interpersonal therapy can be helpful for some patients with severe mental illness because their illnesses often cause problems in their social relationships.
8. Show Slide 118: Family-Focused Therapy.
Tell participants that family-focused therapy can be one of the most helpful types of therapy for patients with severe mental illness. Explain that family dynamics are often stressed when a member of the family has a severe mental illness. Families may blame the patient for their symptoms, or be hostile towards the patient. Often, families feel helpless and hopeless to control the illness. Unfortunately, this stressful home environment can lead to the worsening of the patient’s symptoms, creating a cycle of stress in the home. Family-focused therapy emphasizes the importance of building family support through education, problem solving techniques and communication skills.
15 minutes
9. Explain to participants that all of the therapy approaches previously mentioned include educating the patient and their family. Because of the importance of psychoeducation, all Zamni Lasante health providers have a role in delivering psychoeducation. Psychologists and social workers will practice psychotherapy that includes psychoeducation components, while the other cadres of health workers will provide basic education around severe mental illness.
10. Tell the participants they are now going to brainstorm important psychoeducation messages to share with patients and their families. Draw three columns on a piece of flip chart paper. On top of column one write “general messages,” on top of column two write “psychosis-specific messages,” and on top of column three write “bipolar-specific messages.”
Ask participants:
• What are key messages to share with patients and families when counseling them?
Have the participants respond while you write the answers on the flip chart. All answers in column one should be exhausted before continuing to column two, and then column three. Add any ideas from below that are not mentioned by the group.
66 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTES
GENERAL MESSAGES TO SHARE WITH PATIENTS AND FAMILIES
• A patient’s symptoms can improve with treatment and they can even recover.
• It is important to continue with work, social, and school activities as much as possible.
• The patient has a right to be involved in making decisions about their treatment.
• It is important to exercise, eat healthy, and maintain good personal hygiene.
• Families should not tie up or lock up patients. Instead, bring them to the clinic/hospital or ask the CHW for help/support.
• Information about medication:
– It is important to take the medication regularly and not miss a dose.
– Do not double up on a dose if a dose is missed.
– It is important to continue to take medication even if symptoms improve.
– Symptoms may worsen if medication is discontinued.
PSYCHOSIS-SPECIFIC MESSAGES
• Psychosis is a medical condition that is treatable.
• Psychosis is not contagious.
• Patients with psychosis are often stigmatized and mistreated.
• Many patients recover from psychosis with medication and therapy and return to their normal functioning.
• The patient may hear voices or may firmly believe things that are untrue.
• The patient often does not agree that he or she is ill and may sometimes be hostile.
• If there is a return/worsening of symptoms the patient should come back for re-assessment.
• The patient should be included in family and social activities.
• Family members should avoid expressing criticism or hostility towards the patient.
• The patient may have difficulties recovering or functioning in high-stress working or living environments.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 67
BIPOLAR-SPECIFIC MESSAGES
• It is important for the patient to maintain a regular sleep cycle (e.g. going to bed at the same time every night, trying to sleep the same amount as before illness, avoiding sleeping much less than usual). Difficulty sleeping, if it is persistent, can be helped with medication.
• Relapses can be prevented, by recognizing when a patient’s symptoms return, such as sleeping less, spending more money or feeling much more energetic than usual. The patient should come back for treatment when this occurs.
• A patient in a manic state can lack insight into the illness and may even enjoy the euphoria and improved energy, so carers must be part of relapse prevention.
• Alcohol and other psychoactive substances should be avoided.
40 minutes
11. Show Slide 119: Case Study: Family and Patient Education.
Tell the participants they will practice counseling patients and families about severe mental illness.
12. Divide the participants into four groups. Assign each group of participants one case study (refer to Facilitator Notes). Give the participants 10 minutes to brainstorm psychoeducation messages related to their case study.
Participants should consider:
• What questions to ask the patient and family.
• How and when to share key messages.
• How to involve other health providers in this case to continue supporting the patient and family.
13. At the end of the 10 minutes, invite each group to the front of the room to present their cases and related psychoeducation messaging.
14. After thanking the groups for presenting, summarize key learning points and ask the participants what questions still remain.
68 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTES
CASE STUDY 1
• Gerard is a 25-year-old man with bipolar disorder. He is a patient of yours that you have seen for the past year and the physician has prescribed him carbamazepine.
• His mother, Amelie, has accompanied Gerard to the health center.
• Amelie says that Gerard stopped taking his medication a week ago. She says he has been acting “crazy.” Gerard confirms that he stopped taking his medication, but says he did so to see if he was cured.
• The psychologist/social worker counsels Gerard and his mother.
CASE STUDY 2
• Rose is a 21-year-old who has been accompanied to the health center by her older sister and a community health worker. Rose is clearly agitated, having visual hallucinations and speaking to someone who is not there.
• The older sister tells the psychologist/social worker that for the past three days she has been like this. The older sister says that someone has put a spell on her.
• The community health worker says that Rose has a fever and that Rose’s mother is also sick with a fever.
• The psychologist/social worker counsels Rose’s sister and community health worker about Rose’s condition and the process of determining if this is a medical illness or psychiatric illness.
CASE STUDY 3
• Jean is a 19-year-old man who is disheveled and was brought to the clinic by his brother.
• Jean’s brother explains that Jean has stopped going out with friends and refuses to leave his house. Jean hasn’t attended his university classes in a month. Jean’s brother sometimes sees Jean talking to himself.
• Jean refuses to speak to the psychologist/social worker. The psychologist/social worker shares general mental health messages with Jean and his brother.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 69
CASE STUDY 4
• Ronald is a 55-year-old man who is brought to the clinic by his wife and son.
• Ronald’s wife, Esther, explains that Ronald went out last night and spent all their money. He was up all night, repeating that he was the King of Haiti. She said he has had many of these types of days since they first met 25 years ago. Ronald’s son is very angry that Ronald has spent all their money and demands that the psychologist fixes Ronald’s disturbed mind.
• The psychologist/social worker counsels Esther and her son.
70 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
SESSION 10: Clinical Outcome Measures — CGI and WHODAS
Methods: Facilitator presentation
Time: 2 hours
Participant Handbook page: 44
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 120 – 136 � Flip chart
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 120 – 136.• Photocopy the CGI (1 copy/participant).
Objectives:y. Describe how to use the CGI and WHODAS to assess clinical improvement.z. Explain the importance of outcome measures to assess care quality and systems
improvement.
STEPS
20 minutes
1. Show Slide 120: Session 10: Clinical Outcome Measures – CGI and WHODAS.
Tell the participants that effective care is that which has been shown to improve functioning and quality of life. Effective care may be based on several different types and levels of evidence, and it reflects the best care a system can offer at any given point. To measure effective care, the Zamni Lasante system of care will use the Clinical Global Impressions Scale (known as “CGI”) and the World Health Organization Disability Assessment Schedule (known as “WHODAS”).
2. Show Slide 121: Clinical Global Impressions Scale (CGI).
Explain that the Clinical Global Impressions Scale (CGI) is an easily adopted tool that measures the effect of treatment over time. It is a global assessment of current symptoms, behavior, and the impact of illness on functioning. Its goal is to allow the clinician to rate the severity of illness (CGI-S), change over time (CGI-I), and efficacy of medication.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 71
3. Tell the participants that they will complete the CGI when they first meet with a patient, then every time they meet with a patient (but not more frequently than once per week). Have the participants open their participant handbook to the annex where they can find the CGI Scale. Explain that there are three different measures on the CGI:
• Severity scale – which assesses a patient’s symptom severity over the past 7 days.
• Improvement scale – which measures the overall clinical change of the patient using the baseline assessment as the reference point.
• Side-effects scale – which analyzes the side-effects of the medication.
Allow the participants to read over the CGI scale.
4. Show Slide 122: CGI – Severity.
Explain that psychologists/social workers will determine the CGI Severity by assessing how ill the patient is at the time of interview relative to the psychologist/social worker’s past experience with patients who have the same diagnosis. The psychologist/social worker will judge the level of mental illness that the patient has experienced over the past 7 days.
CGI SEVERITY TIPS
• Err on the side of a more severe rating if in doubt between two values
• Always use the same time period (past seven days)
• Do not compare the patient to a superior functioning person: compare “relative to your past experience with patients who have the same diagnosis…considering your total clinical experience with this population.”
5. Show Slide 123: CGI Severity.
Tell the participants they will now have an opportunity to practice scoring the CGI-S through two case studies. Read aloud Case 1 and begin a discussion about the patient’s level of severity.
72 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CASE 1
A 38-year-old, well-groomed, female patient, who is a successful professional, reports a one-month unprecipitated depressive episode that seems to be worsening. She is currently experiencing early morning awakening, loss of pleasure in her usual activities, feelings of guilt, reduced appetite, tearfulness, and depressed mood. She has found herself weeping several times over the past week, but cannot identify a reason. She is continuing to work, but found herself fighting back tears at an important meeting and believes her work may be less sharp than it had been in the past. No one has noticed, but she is concerned that the depression is worsening and may result in a significant impact on work. She is worried that she may lose her “edge.” She denies suicidal ideation. She has no previous psychiatric history.
6. Ask participants what rating they might give the patient in the case, and why. Once you have taken several ideas from the participants, explain that a suggested CGI-S score for this case is a 4 (moderately ill). Explain the following rationale to the participants. Answer questions as they arise.
RATIONALE
This patient has symptoms that are consistent with major depressive disorder and are beginning to affect her functioning. She might benefit from medication. These elements both suggest a score no less than a 4 (moderate). The patient’s functioning at a very demanding job is only affected to a limited degree at this point; no one has noticed and her lessened performance does not seem extreme. She continues to work her normal schedule. Although distressed, her illness has not caused a distinct impairment of occupational function that would raise the score to a 5 (markedly ill).
7. Show Slide 124: CGI Severity.
Tell the participants they will now have the opportunity to practice scoring a case individually. Ask the participants to take three minutes to read Case 2.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 73
CASE 2
A 34-year-old, male patient with a diagnosis of paranoid schizophrenia has been in treatment at Zanmi Lasante for the past several years, having started medication treatment more than ten years ago after a hospitalization at Mars and Kline. According to his community health worker and physician, he had been stable on his medication regimen for the past year, but recently stopped taking his medication and would not cite a reason. He attended his church twice this past week, but missed four other days which he usually would have attended. After receiving a call from a family member, the community health worker went to his home and drove him to the hospital for evaluation and possible hospitalization. The community health worker reports he has become increasingly threatening and difficult to manage at home, and has been seen responding to auditory hallucinations, including taking cover in attempts to hide from “enemies.” In the past week, he obeyed a command hallucination to “go after” a neighbor, but was physically circumvented from harming the neighbor by three community health workers, who physically restrained him. The community health worker reported that although the patient was passively cooperative about coming to the clinic, he did not speak with her at all during the trip. In the clinic office, he is guarded and suspicious. He mumbles under his breath, but refuses to elaborate as to what he has said or to whom it was directed. Twice he makes a fist and raises his arm threateningly in the direction of the physician, but then puts his hand back in his lap. He appears disheveled and is not groomed; he has not changed his clothing over the past week, which his community health worker reports is a new behavior for him.
8. Ask the participants: by a show of hands, who gave the patient a score of one? Two? Continue asking until you reach seven. Ask if any participants would like share their answers and the reasoning behind their answers.
9. Tell the participants that a suggested CGI-S Score for this case is a 6 (severely ill). Explain the following rationale to the participants. Answer questions as they arise.
RATIONALE
The patient’s functioning is clearly affected by his symptoms to the extent that he is not attending church or taking his medication. Previously well groomed, he has now stopped even basic elements of self-care and hygiene. His behavior required restraint and may have posed a physical risk to others. This is a patient one might actively consider hospitalizing. Based upon his disruptive pathology and behavior influenced by symptoms (hallucinations), a CGI-S score of 6 (severely ill) is warranted. This patient did attend his church one day and did willingly accompany the community health worker to his visit with the psychologist, suggesting a somewhat lessened level of severity than a 7 would imply.
74 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
30 minutes
10. Show Slide 125: CGI – Improvement.
Tell the participants that the next part of the CGI focuses on improvement. When completing the CGI Improvement (CGI-I) section, the participants need to first indicate whether this is an initial evaluation using the CGI, or a follow-up appointment. Explain the following:
• At Initial Evaluation: If the patient has been in treatment previously, rate CGI-I based on the history and compared to the patient’s condition prior to treatment. Otherwise, select 0, “not assessed.”
• Follow-Up Appointment: Rate CGI-I by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.
11. Show slide 126: CGI Improvement.
Tell the participants they will now have an opportunity to practice scoring the CGI-I through two case studies. Read aloud Case 1 and begin a discussion about the patient’s level of severity.
CASE 1
A patient who has been in treatment and receiving an SSRI for an anxiety disorder for four months comes in for a medication check. The patient’s CGI-S at the visit at which SSRI medication was initiated (“baseline” visit) was 4 (moderate). At today’s visit, the patient reports that the anxiety symptoms have decreased considerably. The patient is now able to sleep 7 to 8 hours each night, with no initial insomnia. This represents a significant change from baseline, at which time the patient spent 2 to 3 hours each night trying to fall asleep, with a nightly total of 4 to 5 hours of fitful sleep. The patient reports having felt excessively anxious this week about running out of gas and about a burglar entering the house. The estimated time spent engaged in these anxious thoughts was less than one hour per day, compared to an estimated 3 to 4 hours per day at baseline. The patient drove over a bridge this week, which was described as somewhat difficult and fear-provoking, but manageable. At baseline, the subject was wholly avoidant of bridges, which caused him to drive 30 minutes out of his way each day to get to work.
12. Ask the participants what rating they might give the patient in the case, and why. Once you have taken several ideas from the participants, tell the participants that a suggested CGI-I Score for this case is a 2 (much improved). Explain the following rationale to the participants. Answer questions as they arise.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 75
RATIONALE
The patient’s clinical status has clearly changed in the direction of improvement. For a CGI-I score of 3 (minimally improved), the level of change would not be sufficient to make an appreciable difference to the patient’s clinical status, level of distress, or functioning. This patient is now experiencing a significant nightly improvement in sleep, a reduction in time spent engaged in worry, and is driving over bridges allowing him to cut 60 minutes off his daily commute. These improvements in distress level, symptom severity, and functional ability suggest an improvement score better than 3 because of his noticeable clinical improvement and better functioning. Nonetheless, the patient is still symptomatic; he endures the drive over the bridge with distress and still experiences anxious ruminations each day. Consequently, a rating of 2, much improved, rather than 1, very much improved, best captures this patient’s improvement relative to his baseline state.
13. Show slide 127: CGI Improvement.
Tell the participants they will now have the opportunity to practice scoring a case individually. Ask a participant to read aloud Case 2 and then give participants three minutes to fill in the CGI – Improvement practice document in their participant handbook.
CASE 2
The anxious patient in the previous example (CGI-I Case 1) returns one month later. He reports that he is now afraid of leaving his house without accompaniment. This is a new development for him. He is anxious and worried all day long. He called work and told them he had the flu. In reality, he was afraid to leave his house. He has only left the house three times this week, including his visit to the clinic today, all accompanied by his wife. He felt panicky on all three occasions. Although he denies any lightheadedness or other symptoms suggesting impending syncope, he reports worrying constantly about “passing out” in front of a moving car or bus. He is fearful that he will forget the name of a well-known friend or relative should they call him on the phone. He is sleeping only 1 to 2 hours a night. His wife reports that she has “never seen him so bad.” He cries in the interview and admits he has considered “ending it all” to make the pain go away.
14. Ask the participants: by a show of hands, who gave the patient a score of one? Two? Continue asking until you reach seven.
15. Ask if any participants would like share their answers and their reasoning behind their answers. Tell the participants that a suggested CGI-I Score for this case is a 7 (very much worse). Explain the following rationale to the participants. Answer questions as they arise.
76 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
RATIONALE
The patient has clearly worsened relative to his baseline condition. The patient has stopped going to work and is barely leaving his home. His worries are almost constant, clearly excessive, and are virtually all-consuming. The worries have become less reality-based and are a source of almost unendurable mental distress. He is barely sleeping. The patient finds his situation painful to the point of entertaining suicidal thoughts. Overall, the patient’s level of symptoms, frequency of symptoms, and its effect on his functioning are far above a CGI-I of 5, (minimally worse), or even 6, much worse. His clinical status, relative to baseline, reflects a severe exacerbation of symptoms with a loss of functioning suggesting a CGI-I score of 7 (very much worse). As the ultimate decision-maker, the clinician rater decides if the patient rates a 6 or a 7. What is most important is that ratings are consistent across time and across patients.
16. Show Slide 128: CGI – Side-Effects.
Explain that the side-effects scale scores a patient’s level of side-effects from medication on a scale of 0 – 3. The closer the number is to zero, the better. Remind the participants that medication side-effects will be monitored by physicians using the Abnormal Involuntary Movements Scale (AIMS). The psychologist’s /social worker’s role is not to actively check or identify side-effects. Rather, the CGI Side-Effects scale is simply used to serve as an additional tracking tool, and to double-check what the physician has found in his AIMS evaluation.
17. Explain to the participants that the CGI Side-Effects scale is only used after a patient has begun medication. If a patient is not actively taking medication, then the psychologist/social worker does not need to fill in the side-effects scale. Tell the participants that they will be tracking their patients’ ratings for severity, improvement and side-effects (if relevant) over time, and will be recording this information in a place where they can get a snapshot of the progress of the patient.
30 minutes
18. Show Slide 129: World Health Organization Disability Assessment Schedule.
Tell the participants that another tool that psychologists/social workers will use to track patients’ progress over time is the WHODAS. There are six domains of functioning in the WHODAS that will be discussed with the patient and then recorded. Tell the participants that they will complete the WHODAS when they first meet with a patient, then every three months.
19. Have the participants turn to the WHODAS 12-Item Version in their participant handbook annex. Tell the participants that there are several sections of the WHODAS, but the main sections that psychologists/social workers will be training on today is Section 3 – 4.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 77
20. Ask the participants to read over Section 3 silently. Tell the participants that this section tells the psychologist/social worker how to introduce the WHODAS interview to the patient. The words in blue are what the psychologist/social worker should say to the patient.
21. Show Slide 130: WHODAS Flash Cards.
Tell the participants that there are two flashcards that the psychologist/social worker can use to help the patient communicate their answers. The purpose of the flashcards is to provide a visual cue or reminder to the patient about important pieces of information while answering questions. Show the participants the laminated flashcards they have been provided. Flashcard 1 provides information about how “health conditions” and “having difficulty” are defined, and reminds the respondent that the timeframe for evaluation is the past 30 days. The information on this card provides the respondent with useful reminders throughout the interview. Flashcard 2 is the second card to be used in the interview. It provides the response scale to be used for most questions. When introducing this scale to a patient, the psychologist/social worker should read aloud the number and the corresponding word. Explain these cards may or may not be useful depending on the literacy level of the patient.
22. Show Slides 131 – 132: WHODAS – Section 3.
Ask for a participant to read Section 3 aloud, just reading the blue words. Ask if there are any questions about this introductory language, and if everyone understands why the flashcards are shown to the patient.
23. Show Slides 133 – 135: WHODAS – Section 4: Core Questions.
Explain to the participants that when the psychologist/social worker asks a question, they will prompt the patient to give an answer listed on the scale: none, mild, moderate, severe, extreme or cannot do. The psychologist/social worker will then circle the correct answer on the WHODAS, and will continue to the next question. The last few questions in Section 4 asks for the patient to quantify the number of days they were experiencing difficulty with various activities. Ask for a participant to read Section 4 aloud.
24. Tell the participants that occasionally a question will appear that is not applicable to the patient. Maybe the patient doesn’t ever perform the task that the question is asking about, so the patient doesn’t have an answer to give about the level of difficulty doing it. If a patient says a question is not applicable to them, the psychologist/social worker should follow up with: “Can you tell me why this question does not apply to you?” If the question truly does not apply to the patient, the psychologist/social worker should write “not applicable” next to the question on the WHODAS recording form.
25. Show Slide 136: Tips for Using the WHODAS
Read the slide, emphasizing these are important points to administering the WHODAS correctly.
78 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
30 minutes
26. Tell the participants that a participant and facilitator will role play a dialogue related to a WHODAS interview. Choose a participant to fill the psychologist/social worker role. Have both the participant and the facilitator (who will play the role of the patient) move to the front of the room to act out the dialogue found in the Participant Handbook.
27. Have the participants open their handbook to the WHODAS interview dialogue to follow along.
28. Begin the role play, following the script provided in the Participant Handbook. At some point the participant will need to make up some of the dialogue and answer questions as part of the learning experience (there are six questions/fill-in-the-blanks). At these points the facilitator can “freeze” the scene to go over the new dialogue/questions and ask if other participants agree with the answer the participant gave.
29. Conclude by emphasizing that often, patients will not give you the exact answer to the question. It is important to repeat the questions, clarify if necessary and probe with additional questions.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 79
FACILITATOR NOTES
WHODAS ROLE PLAY
Psychologist/Social Worker: “I now want to ask you a few questions. The interview is about difficulties people have because of health conditions. By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs. Do you understand what I mean by health condition?”
Patient: “Yes.”
Psychologist/Social Worker: “Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about: increased effort, discomfort or pain, slowness, changes in the way you do the activity. When answering, I’d like you to think back over the past 30 days.”
Patient: “OK.”
Psychologist/Social Worker: “I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it. Use this scale when responding: none, mild, moderate, severe, extreme or cannot do.”
Patient: “OK.”
Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: standing for long periods such as 30 minutes?”
Patient: “I am always standing.”
Psychologist/Social Worker: 1. “That’s good to hear you are always standing. Did you have any difficulty and can you tell me using the scale: none, mild, moderate, severe, extreme or cannot do?”
(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do?)
Patient: “I did not have any difficulty.”
2. How would you record this answer on the WHODAS scale? Which category would you circle?
a. None
b. Mild
c. Moderate
d. Severe
e. Extreme or cannot do
80 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
WHODAS ROLE PLAY (continued)
Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: taking care of your household responsibilities?”
Patient: “What type of household responsibilities?”
Psychologist/Social Worker: 3. “Things that you normally do around the house to keep the household functioning. An example of this might be…”
(What should you say to the patient to clarify what you mean?)
Patient: “I had no difficulty.”
Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: learning a new task, for example learning how to get to a new place?”
Patient: “I haven’t learned any new tasks.”
Psychologist/Social Worker: 4. “Ok. If you had to learn a new task, such as learning how to get to a new place, how difficult do you think it would be for you?”
(What should you say to the patient to probe about whether this question is not applicable?)
Psychologist/Social Worker: “In the past 30 days, how much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?”
Patient: “I always go to church but I don’t like going to other community activities.”
Psychologist/Social Worker: 5. “OK. But if you were interested in going to other community activities, how difficult would it be for you to join that activity, on a scale of none, mild, moderate, severe, extreme or cannot do? Remember, we are thinking about health status when we answer these questions.”
(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do? Remind the patient these questions are based on his health status.)
Patient: “I can go to everything — it’s just that I don’t want to. I suppose my answer is none.”
Psychologist/Social Worker: “In the past 30 days, how many days were these difficulties present?”
Patient: “Oh, I don’t know. I can’t say.”
Psychologist/Social Worker: 6. “Can you give me your best guess on the number of days these difficulties were present in the past 30 days?”
(What should you say to the patient to obtain the number of days?)
Patient: “I guess I could estimate that four days a month these difficulties were present.”
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 81
SESSION 11: Follow-Up and Documentation
Methods: Facilitator presentation, small group work
Time: 45 minutes
Participant Handbook page: 51
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 137 – 148 � Flip chart � Markers
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 137 – 148.
Objectives:aa. Explain the process of follow-up for people living with psychotic disorders and severe
mental illnesses.ab. Describe the importance of documentation during patient follow-up.
STEPS
45 minutes
1. Show Slide 137: Session 11: Follow-Up and Documentation.
Read the objectives of the session.
2. Show Slide 138: Psychosis Care Pathway.
Remind the participants that this pathway only works with functional follow-up and documentation. Emphasize the importance of using consistent protocols and procedures in continued evaluation and treatment.
3. Show Slide 139: Follow-Up.
Tell the participants that there are certain follow-up activities that need to be accomplished each follow-up visit. Patients should be seen for follow-up appointments every one to two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.
4. Tell the participants they will now be doing an individual activity where they will think about the important elements of patient improvement and documentation. Ask participants to turn to the “Follow-Up Chart” in their participant handbook (refer to Facilitator Notes).
82 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
5. Tell the participants they will spend the next five minutes filling in the two blank columns of the chart individually. Explain that they should reflect on the different column titles and write their corresponding ideas in the chart.
6. Show Slide 140: Activity: Follow-Up.
Animate the title. Ask the participants to share their responses from column two: “How to Determine a Patient’s Improvement in Symptoms”. Tell the participants that they will be determining a patient’s improvement through using the Clinical Global Impressions Scale and WHODAS. A patient’s improvement is also based on the patient and family report, along with a mental status exam.
7. Show Slide 141: Activity: Follow-Up.
Animate the title. Ask the participants to share their responses from column three: “Why is documentation important?”. Emphasize that the documentation for psychosis, including the Mental Health Follow-Up Form will allow psychologists/social workers to provide better care to patients. Explain that all the forms will be collected and managed by the psychologist/social worker and will ultimately go into the patient’s file.
8. Show Slides 142 – 145: Importance of Documentation.
Ask a participant to read the case over the next four slides. Once the four slides have been read, ask for participants’ reactions. Reinforce that documentation:
• Ensures comprehensive evaluation
• Tracks patient evolution
• Improves communication with other providers
• Encourages accountability to patients
• Is a legal document
9. On a piece of flip chart paper, draw two columns. Label the left column “challenges documenting information” and the right column “strategies to ensure documentation.” Ask participants what challenges they face in properly documenting information. Take a few responses. Then, divide up the participants into groups of two to three and tell them they have five minutes to brainstorm strategies to the overcome the barriers listed on the flip chart.
10. After five minutes, have a representative from each small group share their strategies with the entire group. Record participants’ strategies in the right column on the flip chart.
11. Show Slides 146 – 148: Documentation Question 1 – Documentation Question 3.
Read the question presented on the slide. After asking the question, give the participants time to look at the documents and determine where to document. Allow several participants to give responses before animating the answer.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 83
SESSION 12: Using mhGAP for Psychosis and Bipolar Disorder
Methods: Large group discussion and role play
Time: 45 minutes
Participant Handbook page: 52
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 149 – 163 � Flip chart
� Markers � mhGAP (1 copy/participant)
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 149 – 163.
Objectives:ac. Describe how to use mhGAP for the management of Psychosis and Bipolar Disorder.ad. Describe how to use mhGAP for the management of self-harm/suicide.
STEPS
30 minutes
1. Show Slide 149: Session 12: Using mhGAP for Psychosis and Bipolar Disorder.
Tell the participants that in this next session they will learn about mhGAP and how it connects to their work with agitation, delirium and psychosis. Read the objectives on the slide.
2. Show Slide 150: mhGAP.
Remind the participants that they have been introduced to mhGAP in previous trainings. The mhGAP Intervention Guide is a document developed by the World Health Organization that outlines the diagnosis and management of various mental health disorders. It is designed to serve as a guide for clinicians around the world.
3. Ask the participants:
• Has anyone referenced mhGAP in their work?
If so, ask for the participant(s) to describe the experience of using mhGAP.
84 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
4. Show Slide 151: Range of Psychotic Interventions.
5. Show Slide 152: Psychosis.
Have the participants open their mhGAP to page 18 and choose a participant to read Step 1 in the psychosis assessment section aloud. Mention that the participants have already learned about these acute symptoms of psychosis.
6. Show Slide 153: Ways to Ask about Psychosis.
Tell participants that in some cases it is not clear which symptoms a patient has. By asking questions listed on the slide, the psychologist/social worker can better determine if the if a patient has psychotic features.
7. Show Slide 154: Determining Chronic vs. Acute.
Explain that by asking the patient or carer about the onset of the psychotic episode and any prior episodes, psychologists/social workers will be able to determine if the person has acute psychosis or chronic psychosis. For acute psychosis, the physician will want to stop the medication at some point stop to see if the patient can recover without the medication. Medications have potentially significant side-effects, and clinicians should minimize the use of medication as much as possible. Call on a participant to read Box 2 about chronic psychosis.
Tell participants: The red box in the middle of page 18 in mhGAP emphasizes the importance of ruling out medical delirium before prescribing any medication to someone with acute psychosis —just as you learned about earlier during this training.
8. Ask the participants to take a minute and read silently the two end boxes on page 18 that describe the actions for a patient with acute and chronic psychosis. Ask the participants what similar actions are mentioned by these boxes for patients with psychosis. Answers should include:
• Provide education to patient and carers
• Begin medication
• Provide psychological interventions
• Provide follow-up
• Maintain hope
9. Highlight that the actions mentioned in the mhGAP mirror the actions taken collectively by physicians, psychologists/social workers, nurses and CHWs in the Zanmi Lasante system of care.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 85
10. Show Slide 155: Mania and Concurrent Conditions.
Have the participants turn to the next page in mhGAP (page 19), which guides the reader through the diagnosis of mania and concurrent conditions. Allow the participants to read this page silently. Mention the fact that it is common that patients may be suffering from multiple mental or physical health conditions at once. Conditions should be treated as necessary. Those who are pregnant or of child-bearing age should be prescribed medication with caution.
11. Show Slide 156: Psychoeducation.
Have the participants continue to the next page in mhGAP (page 20). Mention that one of the most useful tools that mhGAP provides to clinicians is psychoeducation messages. The messages on this page are psychosis-specific. Allow participants to read over the psycho-education materials in their mhGAP.
12. Show Slide 157: Bipolar Disorder.
Tell the participants to turn to page 24 in mhGAP. Call on a participant to read the bipolar assessment and management section on page 24 aloud. Tell participants that this first page of mhGAP for bipolar disorder assists clinicians to decide if a patient has bipolar disorder with just manic symptoms, or if the patient has bipolar depression.
13. Ask the participants to take a minute and review the two end boxes on page 24. Ask the participants to think about the differences between treatment for a patient who is has bipolar disorder with mania and a patient with bipolar depression. Once you have given the participants a minute, ask the participants to turn to their neighbor to take one minute to discuss the differences they observe. Ask for a few participants to share their ideas with the group.
14. Show Slide 158: Concurrent Conditions or History of Mania.
Tell the participants to turn to the next page in mhGAP (page 25) which covers screening for the presence of other conditions or a past history of mania. Note that if a patient is not currently experiencing mania, but has a history of mania, the physician should start that patient on a mood stabilizer.
15. Tell the participants to turn to page 26 which describes special populations. Pregnant women, the elderly and adolescents should be prescribed medication with caution.
16. Show Slide 159: Psychoeducation.
Explain that like psychosis, mhGAP provides clinicians with bipolar disorder-specific messages. Allow the participants to read over the bipolar disorder-specific messages. Ask if there are any questions.
86 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
15 minutes
17. Show Slide 160: Self-Harm/Suicide.
Explain that mhGAP can help psychologists/social workers assess a patient for self-harm and can guide the psychologist/social worker to take the appropriate next steps. Instruct the participants to turn to page 74 in mhGAP and take a few minutes to look through the first step of the Self-Harm/Suicide protocol.
18. Emphasize that no matter the condition of the patient, it is important not to leave the patient alone. Ask the participants: what does “offer and activate psychosocial support” mean?
19. Ask the participants to turn to the next page in mhGAP (page 75). Have a participant read the page aloud to the group.
20. Tell the participants that they will now practice making decisions around self-harm and suicide. Explain that you will facilitate a quick quiz that asks participants to judge if there is an imminent risk of self-harm/suicide.
21. Show Slides 161 – 162: Is There an Imminent Risk?
Read the case on the slide aloud. Tell the participants that this case is also in their participant handbook.
Ask the participants, by a show of hands, who thinks that “yes, there is an imminent risk”? Wait for participants to raise their hands. Then ask them to raise a hand if they do not think that “there is an imminent risk.” Animate the answer.
22. Instruct the participants to turn to the next page in mhGAP (page 76) and read over the flow diagram. Tell the participants that just like psychosis and bipolar disorder, the self-harm/suicide chapter recognizes that there can be concurrent conditions, including complex emotional or pain symptoms. Instruct the participants to take time to also read the following page (77) which details how to facilitate a supportive environment for someone who is at risk of self-harm/suicide.
23. Show Slide 163: mhGAP Guides All Work.
Conclude by reminding the participants that mhGAP is a guide not only for psychosis and bipolar disorder, but also for depression, epilepsy and other conditions. Encourage the participants to use mhGAP along with the DSM IV to help inform their methods of working with patients living with mental disorders. Ask the participants if there are any remaining questions.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 87
SESSION 13: Review, Post-Test and Training Evaluation
Methods: Case studies, assessment, evaluation
Time: 2 hours 30 minutes
Participant Handbook page: 54
Materials: � PowerPoint (Agitation, Delirium,
and Psychosis), slides 164 –165 � Flip chart � Markers � Post-it notes
� Post-Test Answer Key (downloaded on a computer to be projected)
� Training Evaluation Forms (1 copy/participant)
� Post-Test (1 copy/participant)
Preparation:
• Review PowerPoint (Agitation, Delirium, and Psychosis), slides 164 –165.• Review the case studies ahead of time.• Photocopy the post-tests and training evaluation forms.• Create three flip chart pages, each individually titled:
1. How will you share what you’ve learned?
2. What strategies will you use to ensure collaboration with other team members?
3. When I’m unsure or struggling I will…
Objectives:ae. Review all unit objectives.af. Demonstrate learning through a post-test.ag. Give feedback on the training.
STEPS
1 hour
1. Show Slide 164: Session 13: Review Session, Post-Test and Training Evaluation.
Explain to the participants that they will discuss case studies as a way to review both the management of patients with severe mental illness and to become familiar with the forms and tools that are available to help with patient management.
2. Divide the participants into small groups of three or four people.
88 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. Have them turn to the case studies in their participant handbook. Tell the participants that the case studies are formatted like stories. They should read the first part of the case, respond accordingly, and then continue on to the next part of the case.
4. Tell the participants they will have 40 minutes to complete the case study questions.
5. Remind the participants to reference the tools and forms with which they have been provided. Encourage them to think about the system of care more broadly and their roles within the system. Ask the participants to consider how they should best work with community health workers, nurses, and physicians.
6. After 40 minutes, ask everyone to join the larger group again. Review the case studies by asking a different group to present each case and their answers. Use the questions included in the case studies to guide the discussion.
7. Answer any questions that arise.
Post-Test:
40 minutes
8. After the case study discussions have finished, administer the post-test to the participants. Allow them 30 minutes to complete the post-test.
9. Once the post-test has finished, and all tests have been collected, project the post-test answer key. Go over each question and the correct answer. Answer any questions that arise from the participants.
Reflection:
20 minutes
10. Hang up the three pre-written flip chart pages on three separate walls in the training space.
11. Show Slide 165: Reflection.
Tell the participants they will spend a few minutes reflecting on this training. Pass out three Post-it notes to each participant. Instruct them to reflect and write down an answer for each of the three questions (listed on the slide) on a different Post-it note. There is no need for them to put their name on the Post-it notes, as this is an anonymous activity.
12. Once they have finished writing their three Post-it notes, they should go and post their Post-it notes on the corresponding flip chart page. Once the participants have posted their Post-it notes, all the participants should circulate between the three flip chart pages to view what others have written.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 89
13. After all the participants have had a few minutes to circulate and read others’ reflections, ask them to sit down.
14. Conclude by taking down the pages and reading all answers aloud to the group. Highlight similar answers and unique ideas.
Evaluation:
30 minutes
15. Explain that you would like to gather the participants’ comments and feedback on this training, in order to revise and improve future trainings if needed.
16. Give each participant an evaluation form. As the participants work, circulate and help as needed.
17. Once all the participants have finished their evaluations, collect the written evaluation forms.
18. Congratulate the participants on having completed this training. Thank them for their participation. Distribute certificates as appropriate.
90 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
FACILITATOR NOTES
CASE STUDY 1
A 40-year-old woman is brought into the health facility by her two sons. She is barely able to walk and is clearly confused. She cannot follow simple commands. Her sons said she has been fatigued and feverish for the past few days. The patient is mildly agitated, clearly frustrated with her sons. You, the nurse and the physician are available to evaluate and manage the patient.
1. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?
Support the physician:
• Ensure the physician uses the Medical Evaluation Protocols
• Ensure the physician completes the Agitated Patient Form
• Ensure medication is given if necessary
Forms to help manage:
• Use Agitation, Delirium and Psychosis Checklist
• Agitated Patient Protocol
• Medical Evaluation Protocols for Agitation, Delirium and Psychosis
The physician has concluded that the patient likely needs further neurological testing to determine if the patient has a neurological problem. The patient also has a confirmed fever above 38 C. The two sons said that they are sad that she is now “crazy” and want to know how you can cure her.
2. What would you say to the two sons?
• Emphasize that most likely, their mother does not have a mental disorder and should not be considered “crazy.”
• Explain that through further testing, the physician might be able to identify the medical issue and then identify possible solutions.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 91
CASE STUDY 2
A 27-year-old man, Pierre, is brought into the health center by two community health workers. He is yelling that the community health workers are trying to kill him. He lunges at anyone who tries to get close to him, screaming that he will kill everyone.
1. Is this patient agitated. What level of agitation does the patient have?
• The patient is severely agitated
2. What do you do to manage the behavior and environment? Who do you collaborate with?
What you do:
• Manage behavior and environment
– Use calming interventions, such as talking with the patient or arranging a 1:1
– Show sympathy and empathy, make eye contact
– Allow the patient to show anger
– Decrease stimulation
– Keep yourself and the staff safe by using safety considerations including removing objects that can be used to harm
Collaborate with:
• The nurse
• The physician
3. What forms would you use to assist you to manage this agitated patient?
• Agitation, Delirium and Psychosis Checklist
• Agitated Patient Protocol
• Agitation, Delirium and Psychosis Form (assist the physician with this document)
After a few minutes of speaking calmly with the patient you leave the room, and identify someone to keep an eye on the patient to ensure his safety and that of others (1:1). You have been able to calm the patient without giving any medications and the physician has done an initial medical evaluation. The patient denies wanting to hurt himself or others. His lab tests have come back normal and the physician says he is not suffering from medical delirium.
4. What would you do next? What forms would you be utilizing to guide your work?
Next steps:
• Complete ZLDSI
• Use Suicidality Screening Instrument (if needed)
• Speak with patient and family and begin to complete Initial Mental Health Evaluation Form
92 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CASE STUDY 2 (continued)
Forms to utilize:
• Agitation, Delirium and Psychosis Form
• Agitation, Delirium and Psychosis Checklist
• Initial Mental Health Evaluation Form
• ZLDSI
• Suicidality Screening Instrument (if needed)
You see the patient for an initial mental health evaluation and the patient reports that he has been hearing voices that tell him that everyone wants to kill him. He is disheveled and it is apparent he has not bathed in many days. You ask the community health workers about the patient, and they say that he is typically locked in the house by his family. However, the community health workers were able to convince the family to let him come to the health facility. The community health workers say the patient has been this way for a few years. You are unable to get further information from the patient as his speech is disorganized and tangential.
5. What diagnosis would you give the patient? Why? Where would you record the diagnosis?
• Schizophrenia. The patient has delusions and hallucinations. The patient has disorganized speech and is disconnected from reality. This psychotic behavior has been happening for more than six months and seems to be continuous.
• The diagnosis would be recorded in the Initial Mental Health Evaluation Form.
6. What clinical formulation would you record on the Initial Mental Health Evaluation Form?
• Pierre is a 27-year-old male who was brought to the health facility by two community health workers. Pierre is reportedly locked inside the house by his family and left isolated much of the day. Pierre can hear threatening voices in his head. From a biological perspective, it is unclear if any family members suffer from mental illness. From a psychological perspective, Pierre is clearly affected by his illness, as he is unable to carry on a conversation and appears out of touch with reality. Pierre is socially isolated and has poor hygiene. It is unknown what Pierre’s strengths are presently. It appears that Pierre has had this illness for the past few years, but has never received treatment. It appears that Pierre is suffering from psychosis, and specifically, schizophrenia. Further history and observation will help in clarifying the diagnosis. In the meantime the treatment team will focus on treating his acute psychosis and agitation and will work to stabilize the situation in collaboration with him and his family.
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Partners In Health | FACILITATOR MANUAL 93
CASE STUDY 2 (continued)
7. What type of psychotherapy would you consider beginning with the patient during the next visit? Why?
• Supportive Therapy – specifically for low-functioning adults with schizophrenia
• Family-Focused Therapy – involve family in therapy to help rehabilitate patient and improve living situation
8. After diagnosis, how would you collaborate with the physician that day?
• Accompany the patient to get medication from the physician
• Support the physician in giving psychoeducation about medication
• Plan follow-up
9. What would be the follow-up plan for this patient? What other providers would you include, and what would their role be?
• The patient should return within one week because they just began treatment.
• The patient should return to see both the psychologist/social worker and physician. The psychologist/social worker should ensure that the CHW is providing support in the community to the patient and his family.
• The patient would begin psychotherapy during a follow-up appointment.
94 Partners In Health | FACILITATOR MANUAL
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CASE STUDY 3
This past year you began seeing a young, 18-year-old woman with a recent episode of psychosis. She was prescribed risperidone. Today during her monthly follow-up visit, approximately 8 months since the initiation of medication, you notice that she appears restless, frequently wringing her hands and looking upset.
1. What forms will you use or complete during your follow-up visit?
Use:
• Agitation, Delirium and Psychosis Checklist
Complete:
• CGI
• Mental Health Follow-Up Form
• Registry
During her appointment, when you ask her how things are going, she begins to cry and tells you that things are not going well. She recently broke up with her boyfriend and cannot find a job to support herself.
2. How would you counsel her? What are some key messages you would give her during this time of stress?
• It is important to continue taking her medication.
• She should visit you (the psychologist/social worker) with more frequency, if needed.
• She should look to her social supports for assistance during this time.
You are worried that this stress could trigger a relapse.
3. How would you collaborate with other providers to ensures she is adherent to her medication and has social support during this time of stress?
• Speak with the physician and CHW about medication adherence and support.
• Offer to see the patient more frequently for support.
95Partners In Health | FACILITATOR MANUAL | ANNEX
Annex
96 Partners In Health | FACILITATOR MANUAL | ANNEX
� PRE-TEST � POST-TEST (check one)
Name: Date:
Site: Supervisor:
1. Combined, psychotic and mood disorders such as schizophrenia and ( / 1 point) bipolar disorder affect how many people worldwide? (Choose one)
a. 5 million people
b. 81 million people
c. 500 million people
d. 25 million people
2. What are the responsibilities of the psychologist/social worker in the ( / 1 point) psychosis care pathway? (Choose one)
a. Ensure safety for the patient and others through correct agitation management
b. Prescribe anti-psychotic medication
c. Diagnose psychotic patients with mental illness
d. Provide psychotherapy and psychoeducation to patient and families
e. A, C and D
f. All of the above
3. What are the four pillars of emergency management of agitation, delirium, ( / 1 point) and psychosis? (Choose one)
a. Vital signs, history of illness, mental health evaluation, treatment
b. Agitation reduction, physician visit, psychologist visit, CHW visit
c. Physicians, psychologists, social workers, and nurses
d. Safety, medical health, mental health, follow-up
4. Which of the following are biopsychosocial considerations that ( / 1 point) psychologists/social workers should have when approaching the treatment and management of psychotic disorders? (Choose one)
a. Religious and spiritual beliefs
b. Personality
c. Medications
d. Exposure to stigmatization
e. Socioeconomic stressors
f. All of the above
97Partners In Health | FACILITATOR MANUAL | ANNEX
5. You observe a patient in the waiting room who is punching the wall ( / 1 point) and threatening staff. What level of agitation does this patient have? (Choose one)
a. No agitation
b. Mild agitation
c. Moderate agitation
d. Severe agitation
6. When you encounter an agitated patient, what is the first step to managing ( / 1 point) their agitation? (Choose one)
a. Give the patient medication to sedate him
b. Ask the patient to leave the health facility
c. Use calming interventions and talk to try to get as much information from the patient as possible
d. Refer the patient to Mars and Klein
7. Intramuscular medication of an antipsychotic, such as haloperidol, should ( / 1 point) only be used when… (Choose one)
a. A patient is physically aggressive and has refused oral medication
b. A patient is verbally threatening and cursing at staff
c. A patient is running around the emergency room and nurses are scared
d. Intramuscular medication should be used on all agitated patients
8. True or false: Delirium is a psychiatric illness. (Choose one) ( / 1 point)
a. True
b. False
9. What psychotherapy approaches are recommended for psychotic/manic ( / 1 point) patients? (Choose one)
a. Interpersonal Therapy
b. Supportive Therapy
c. Family-Focused Therapy
d. Behavioral Activation
e. A, B and C
f. All of the above
98 Partners In Health | FACILITATOR MANUAL | ANNEX
10. Which of the following could cause a medical delirium? (Choose one) ( / 1 point)
a. Dementia
b. HIV encephalopathy
c. Emotional trauma
d. Alcohol withdrawal
e. A, B, and D
f. None of the above
11. True or False: Agitation is a disease. (Choose one)
a. True
b. False
12. Psychologists are in charge of completing which of the following ( / 1 point) documents for their patients? (Choose one)
a. Initial Mental Health Evaluation Form
b. ZLDSI
c. WHODAS
d. Clinical Global Impressions Scale (CGI)
e. All of the above
13. Which medications below are antipsychotic medications? (Choose one) ( / 1 point)
a. Carbamazepine and haloperidol
b. Haloperidol and diazepam
c. Risperidone and diphenhydramine
d. Haloperidol and risperidone
e. Valproate and carbamazepine
14. What is a safety plan? (Choose one) ( / 1 point)
a. An already-created form that a psychologist/social worker will give to the patient to tell them what to do in case of a suicidal crisis.
b. A plan that the community health worker uses to identify suicidal patients in the community.
c. A two-step plan that tells the patient who to contact and where to go in case of crisis.
d. A six-step plan developed by the psychologist/social worker and patient that guides the patient about what to do if in a suicidal crisis.
99Partners In Health | FACILITATOR MANUAL | ANNEX
15. Clinical formulations recorded on the Initial Mental Health Evaluation Form ( / 1 point) should be composed of which of the following? (Choose one)
a. Biological, psychological, social factors of a patient’s situation
b. Past psychiatric history and active medical problems of a patient
c. Biological, psychological, social factors and strengths of a patient’s situation
d. Chief complaint and diagnosis
16. The Abnormal Involuntary Movement Scale (AIMS) helps physicians to… ( / 1 point) (Choose one)
a. Recognize when a patient has psychotic symptoms
b. Determine how quickly a patient metabolizes medication
c. Identify if a patient is experiencing involuntary movements as part of antipsychotic medication side-effects
d. Monitor an agitated patient’s movement after sedation
17. Brief psychotic disorder is defined as… (Choose one) ( / 1 point)
a. A disorder marked by alternating periods of elation and depression
b. A disorder with symptoms of schizophrenia that are present for 1 – 6 months
c. A disorder with psychotic symptoms in which there is inadequate information to make a diagnosis
d. A disorder with a short-term episode of psychotic thinking that lasts less than a month
18. The World Health Organization Disability Assessment Schedule (WHODAS) ( / 1 point) measures… (Choose one)
a. Six domains of functioning and is an assessment instrument for health and disability
b. Abnormal involuntary movements due to medication side-effects
c. Severity of illness and improvement after beginning treatment
d. None of the above
19. With what frequency should physicians see patients for follow-up ( / 1 point) appointments if their symptoms are acute, or if medications are being started or adjusted? (Choose one)
a. Once a month
b. Once every three months
c. Once every 1– 2 weeks
d. Every 5 days
100 Partners In Health | FACILITATOR MANUAL | ANNEX
20. How often should the Clinical Global Impressions Scale (CGI) be ( / 1 point) administered to a patient? (Choose one)
a. Every visit
b. Every six months
c. Once a year
d. Just when the patient is starting a new type of treatment
101Partners In Health | FACILITATOR MANUAL | ANNEX
PRE-TEST AND POST-TEST ANSWER KEY
Name: Date:
Site: Supervisor:
1. Combined, psychotic and mood disorders such as schizophrenia and ( / 1 point) bipolar disorder affect how many people worldwide? (Choose one)
a. 5 million people
b. 81 million people
c. 500 million people
d. 25 million people
2. What are the responsibilities of the psychologist/social worker in the ( / 1 point) psychosis care pathway? (Choose one)
a. Ensure safety for the patient and others through correct agitation management
b. Prescribe anti-psychotic medication
c. Diagnose psychotic patients with mental illness
d. Provide psychotherapy and psychoeducation to patient and families
e. A, C and D
f. All of the above
3. What are the four pillars of emergency management of agitation, delirium, ( / 1 point) and psychosis? (Choose one)
a. Vital signs, history of illness, mental health evaluation, treatment
b. Agitation reduction, physician visit, psychologist visit, CHW visit
c. Physicians, psychologists, social workers, and nurses
d. Safety, medical health, mental health, follow-up
4. Which of the following are biopsychosocial considerations that ( / 1 point) psychologists/social workers should have when approaching the treatment and management of psychotic disorders? (Choose one)
a. Religious and spiritual beliefs
b. Personality
c. Medications
d. Exposure to stigmatization
e. Socioeconomic stressors
f. All of the above
102 Partners In Health | FACILITATOR MANUAL | ANNEX
5. You observe a patient in the waiting room who is punching the wall ( / 1 point) and threatening staff. What level of agitation does this patient have? (Choose one)
a. No agitation
b. Mild agitation
c. Moderate agitation
d. Severe agitation
6. When you encounter an agitated patient, what is the first step to managing ( / 1 point) their agitation? (Choose one)
a. Give the patient medication to sedate him
b. Ask the patient to leave the health facility
c. Use calming interventions and talk to try to get as much information from the patient as possible
d. Refer the patient to Mars and Klein
7. Intramuscular medication of an antipsychotic, such as haloperidol, should ( / 1 point) only be used when… (Choose one)
a. A patient is physically aggressive and has refused oral medication
b. A patient is verbally threatening and cursing at staff
c. A patient is running around the emergency room and nurses are scared
d. Intramuscular medication should be used on all agitated patients
8. True or false: Delirium is a psychiatric illness. (Choose one) ( / 1 point)
a. True
b. False
9. What psychotherapy approaches are recommended for psychotic/manic ( / 1 point) patients? (Choose one)
a. Interpersonal Therapy
b. Supportive Therapy
c. Family-Focused Therapy
d. Behavioral Activation
e. A, B and C
f. All of the above
103Partners In Health | FACILITATOR MANUAL | ANNEX
10. Which of the following could cause a medical delirium? (Choose one) ( / 1 point)
a. Dementia
b. HIV encephalopathy
c. Emotional trauma
d. Alcohol withdrawal
e. A, B, and D
f. None of the above
11. True or False: Agitation is a disease. (Choose one)
a. True
b. False
12. Psychologists are in charge of completing which of the following ( / 1 point) documents for their patients? (Choose one)
a. Initial Mental Health Evaluation Form
b. ZLDSI
c. WHODAS
d. Clinical Global Impressions Scale (CGI)
e. All of the above
13. Which medications below are antipsychotic medications? (Choose one) ( / 1 point)
a. Carbamazepine and haloperidol
b. Haloperidol and diazepam
c. Risperidone and diphenhydramine
d. Haloperidol and risperidone
e. Valproate and carbamazepine
14. What is a safety plan? (Choose one) ( / 1 point)
a. An already-created form that a psychologist/social worker will give to the patient to tell them what to do in case of a suicidal crisis.
b. A plan that the community health worker uses to identify suicidal patients in the community.
c. A two-step plan that tells the patient who to contact and where to go in case of crisis.
d. A six-step plan developed by the psychologist/social worker and patient that guides the patient about what to do if in a suicidal crisis.
104 Partners In Health | FACILITATOR MANUAL | ANNEX
15. Clinical formulations recorded on the Initial Mental Health Evaluation Form ( / 1 point) should be composed of which of the following? (Choose one)
a. Biological, psychological, social factors of a patient’s situation
b. Past psychiatric history and active medical problems of a patient
c. Biological, psychological, social factors and strengths of a patient’s situation
d. Chief complaint and diagnosis
16. The Abnormal Involuntary Movement Scale (AIMS) helps physicians to… ( / 1 point) (Choose one)
a. Recognize when a patient has psychotic symptoms
b. Determine how quickly a patient metabolizes medication
c. Identify if a patient is experiencing involuntary movements as part of antipsychotic medication side-effects
d. Monitor an agitated patient’s movement after sedation
17. Brief psychotic disorder is defined as… (Choose one) ( / 1 point)
a. A disorder marked by alternating periods of elation and depression
b. A disorder with symptoms of schizophrenia that are present for 1 – 6 months
c. A disorder with psychotic symptoms in which there is inadequate information to make a diagnosis
d. A disorder with a short-term episode of psychotic thinking that lasts less than a month
18. The World Health Organization Disability Assessment Schedule (WHODAS) ( / 1 point) measures… (Choose one)
a. Six domains of functioning and is an assessment instrument for health and disability
b. Abnormal involuntary movements due to medication side-effects
c. Severity of illness and improvement after beginning treatment
d. None of the above
19. With what frequency should physicians see patients for follow-up ( / 1 point) appointments if their symptoms are acute, or if medications are being started or adjusted? (Choose one)
a. Once a month
b. Once every three months
c. Once every 1– 2 weeks
d. Every 5 days
105Partners In Health | FACILITATOR MANUAL | ANNEX
20. How often should the Clinical Global Impressions Scale (CGI) be ( / 1 point) administered to a patient? (Choose one)
a. Every visit
b. Every six months
c. Once a year
d. Just when the patient is starting a new type of treatment
106 Partners In Health | FACILITATOR MANUAL | ANNEX
PS
YC
HO
SIS
CA
RE
PA
TH
WA
Y
CA
SE I
DEN
TIFIC
ATI
ON
A
ND
REFER
RA
LEV
ALU
ATI
ON
, D
IAG
NO
SIS
A
ND
TR
EA
TMEN
T
• M
anag
e ag
itate
d pa
tient
• Id
entif
y an
d re
fer
• C
oord
inat
e ca
re
• Ps
ycho
educ
atio
n
• M
anag
e ag
itate
d pa
tient
• Ev
alua
tion,
dia
gnos
is,
and
trea
tmen
t
• M
edic
atio
n m
anag
emen
t
• C
oord
inat
ed c
are
with
psy
chol
ogis
t/SW
• Ps
ycho
educ
atio
n
• Id
entif
y, t
riage
, an
d re
fer
• Ps
ycho
educ
atio
n
• Fo
llow
-up
• C
omm
unity
act
iviti
es
• M
anag
e ag
itate
d pa
tient
• Ev
alua
tion,
dia
gnos
is,
and
trea
tmen
t
• C
oord
inat
e ca
re w
ith
phys
icia
n an
d C
HW
• Ps
ycho
educ
atio
n
• M
EQ/c
heck
list
REFER
Nur
sePh
ysic
ian
Psy
chol
ogis
t or
So
cial
Wor
ker
CH
W
COLLABORATE
FO
LLO
W-U
P
107Partners In Health | FACILITATOR MANUAL | ANNEX
1
DIFFERENTIAL D IAGNOSIS INFORMATION SHEET FOR SEVERE MENTAL D ISORDERS
CONDITION SYMPTOMS DIAGNOSTIC HINTS GENERAL MANAGEMENT
Medical Symptoms or Psychosis Caused by Medical Conditions
Delirium New onset abnormal mental status • Abnormal physical exam, vital signs or laboratory studies
• Abnormal mental status examination
• Seek medical source of illness
• Follow Medical Evaluation Protocol for Agitation, Delirium and PsychosisPsychotic Disorder
Due to a General Medical Condition
Psychosis is the direct physiological consequence of a medical condition
• Psychotic symptoms
• Evidence of a contributing medical illness
Substance-Induced Psychotic Disorder
Prominent hallucinations or delusions • Evidence of recent substance intoxication or withdrawal
Post-Partum Psychosis
New onset psychosis in a female following childbirth
• Recent childbirth
Mental Health Related Symptoms that are not Psychosis
Transient hallucinations
Anomalous experiences, may occur in a person in a state of good mental and physical health, even in the apparent absence of a trigger (stress, fatigue, intoxication, etc.)
• Common in children and youth
• Ensure safety of patient: assess for self-harm
• Seek to understand patient’s explanatory model, and to assess internal level of distress
• Obtain Biopsychosocial history
• Identify potential stressors
• Consult traditional healer if currently involved in management
Acute stress, anxiety, and trauma-related problems
Stress and traumatic experiences can result in unusual sensory and perceptual experiences that can mimic psychosis
• Significant trauma history
Conversion Disorder Usually in response to stress, a person can develop blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation
• Identification of stressor
• Poor insight into emotional stressors
Obsessive-compulsive disorder
Excessive thoughts (obsessions) that can lead to repetitive behaviors (compulsions), with a potential component of disordered thinking
• Specific area of focus
Autism spectrum disorders
A serious developmental disorder that impairs the ability to communicate and interact
• Longstanding history of unstable interpersonal relationships
Personality Disorder A deeply ingrained and maladaptive pattern of behavior of a specified kind, typically manifest by the time one reaches adolescence and causing long-term difficulties in personal relationships or in functioning in society
• Longstanding history of unstable interpersonal relationships
• Poor insight
108 Partners In Health | FACILITATOR MANUAL | ANNEX
2
CONDITION SYMPTOMS DIAGNOSTIC HINTS GENERAL MANAGEMENT
Episodic Psychosis or Mania
Depression with psychotic features (Mood Disorder, depressed)
A primary depression with psychotic symptoms. • Depressive symptoms before psychotic symptoms
• Ensure safety of patient: assess for self-harm
• Seek to understand patient’s explanatory model, and to assess internal level of distress
• Obtain Biopsychosocial history
• Identify potential stressors
• Consult traditional healer if currently involved in management
• Consider co-morbid mental health diagnoses.
• Both depression and psychosis are treated with distinct medications
• Antidepressant medications (fluoxetine, amitryptiline) can cause mania in a person with Bipolar Disorder
Bipolar Disorder (Mood Disorder, manic or depressed)
Marked by alternating periods of elation and depression; some develop mania without depression, others can develop hypomania with depression
• Period of mania, or hypomania with depression
Brief psychotic disorder (less than one month)
A sudden, short-term episode of psychotic thinking and behavior which occurs with a stressful event; can be informed by social and cultural factors
• Person returns to functioning
Schizophreniform Disorder (Schizophrenia symptoms 1-6 months)
Symptoms of schizophrenia are present for a significant portion of the time within a 1-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia
• Do not make diagnosis of Schizophrenia if symptoms are less than 6 months
Psychosis Not Otherwise Specified (NOS)
Psychotic symptoms about which there is inadequate information to make a diagnosis
• Examples include: psychosis of a few days or weeks duration, post-partum psychosis, and situations in which diagnosis is unclear
Differential Diagnosis Information Sheet For Severe Mental Disorders (Continued)
109Partners In Health | FACILITATOR MANUAL | ANNEX
3
CONDITION SYMPTOMS DIAGNOSTIC HINTS GENERAL MANAGEMENT
Continous Psychosis
Schizophrenia (greater than 6 months)
DSM 5 criteria1
Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):
1. Delusions2. Hallucinations3. Disorganized speech 4. Grossly disorganized or catatonic behavior5. Negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one of the above symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts or two or more voices are conversing with each other
Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved before the onset.
Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms and may include periods of prodromal or residual symptoms.
Exclusions:
• Schizoaffective and mood disorder exclusion
• Substance/general medical condition exclusion
• Pervasive developmental disorder- the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least a month
• Consider age at onset
• Consider prodromal period before onset of initial symptoms
• Ensure safety of patient: assess for self-harm
• Seek to understand patient’s explanatory model, and to assess internal level of distress
• Obtain Biopsychosocial history
• Identify potential stressors
• Take conservative approach to medication
• Consult traditional healer if currently involved in management
• Consider co-morbid mental health diagnoses
Delusional disorder (plausible, circumscribed delusions)
Associated with one or more nonbizarre delusions of thinking such as expressing beliefs that can occur in real life, provided no other symptoms of schizophrenia are present
• Delusion is usually realistic
1 DSM-5 Diagnostic criteria for schizophrenia. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fifth edition, Washington, DC, 2013, American Psychiatric Association.
Differential Diagnosis Information Sheet For Severe Mental Disorders (Continued)
110 Partners In Health | FACILITATOR MANUAL | ANNEX
AG
ITA
TIO
N,
DE
LIR
IUM
AN
D P
SY
CH
OS
IS C
HE
CK
LIS
T
Dat
e __
____
____
____
____
____
____
dd
/mm
/yy
CH
WP
SYC
HO
LO
GIS
T/S
OC
IAL
WO
RK
ER
NU
RS
ES
PH
YS
ICIA
N
AG
ITA
TED
PA
TIEN
T
�
Acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
imm
edia
tely
INIT
IAL
EVA
LUA
TIO
N (
ON
CE
CA
LM)
�
If s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
�
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
�
Com
plet
e th
e In
itial
Vis
it Fo
rm
�
Use
the
ZLD
SI
�
Do
psyc
hoed
ucat
ion
�
Giv
e th
e R
efer
ral F
orm
and
Initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/S
W
FOLL
OW
-UP
�
If s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
�
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
�
Doc
umen
t w
ith t
he M
enta
l H
ealth
Fol
low
-Up
Form
�
Use
the
ZLD
SI
�
Do
psyc
hoed
ucat
ion
�
Giv
e th
e R
efer
ral F
orm
and
Initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/S
W
�
Do
follo
w-u
p of
pat
ient
in
the
com
mun
ity (
chec
k pa
tient
ad
here
nce,
sid
e ef
fect
s,
enco
urag
e pa
tient
s to
do
fo
llow
-ups
)
AG
ITA
TED
PA
TIEN
T
�
Acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
�
Ref
er t
o th
e A
gita
ted
Patie
nt P
roto
col;
supp
ort
nurs
e an
d ph
ysic
ian
�
Col
lect
info
rmat
ion
from
pat
ient
and
fam
ily
�
Arr
ange
1:1
if n
eede
d
�
Rem
ain
at b
edsi
de u
ntil
patie
nt is
sta
ble
�
Follo
w p
atie
nt 2
x/da
y, g
ive
phon
e nu
mbe
r to
pat
ient
’s fa
mily
& n
urse
/phy
sici
an
�
Usi
ng A
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list,
ens
ure
med
icat
ions
giv
en a
nd
med
ical
car
e pr
ovid
ed b
y nu
rse/
MD
�
Giv
e pa
tient
/fam
ily p
sych
oedu
catio
n an
d su
ppor
t
�
Ass
ess
& m
anag
e so
cioe
cono
mic
bur
den
of il
lnes
s
�
Proc
eed
to in
itial
eva
luat
ion
(onc
e ca
lm)
INIT
IAL
EVA
LUA
TIO
N (
ON
CE
CA
LM)
�
Com
plet
e Ps
ycho
sis
Che
cklis
t w
ith C
HW
/nur
se
�
Com
plet
e ZL
DSI
�
Doc
umen
t in
Initi
al M
enta
l Hea
lth E
valu
atio
n Fo
rm
�
Spea
k w
ith p
atie
nt a
nd T
WO
fam
ily m
embe
rs &
rev
iew
phy
sici
an’s
Agi
tate
d Pa
tient
For
m t
o co
mpl
ete
initi
al m
enta
l hea
lth e
valu
atio
n
�
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
�
Acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian
(see
s al
l psy
chot
ic, s
uici
dal,
viol
ent
case
s)
�
Hel
p ph
ysic
ian
follo
w c
heck
list
�
Mak
e pr
elim
inar
y di
agno
sis
of d
eliri
um/m
edic
al il
lnes
s or
men
tal i
llnes
s w
ith
the
phys
icia
n
�
If p
atie
nt n
eeds
med
ical
car
e, c
oord
inat
e w
ith p
hysi
cian
s, if
pat
ient
has
ps
ycho
tic d
isor
der,
sche
dule
fol
low
-up
with
in o
ne w
eek
�
Do
psyc
hoed
ucat
ion
and
supp
ort
rela
ted
to m
edic
atio
n an
d ps
ycho
sis
�
Com
plet
e C
GI/
WH
OD
AS,
Reg
istr
y, C
heck
list
FOLL
OW
-UP
�
Use
Men
tal H
ealth
Fol
low
-Up
Form
�
See
whe
ther
pat
ient
is im
prov
ing
(che
ck m
enta
l sta
tus
exam
, fun
ctio
ning
, pa
tient
and
fam
ily r
epor
t)
�
Che
ck m
edic
atio
n co
mpl
ianc
e, s
ide
effe
cts
�
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
�
Acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian;
hel
p ph
ysic
ian
follo
w A
gita
tion,
Del
irium
an
d Ps
ycho
sis
Che
cklis
t
�
Plan
fol
low
-up
for
1– 2
wee
ks; c
oord
inat
e w
ith C
HW
�
Do
psyc
hoed
ucat
ion
and
supp
ort
for
med
icat
ion
and
psyc
hosi
s
�
Com
plet
e C
GI/
WH
OD
AS,
Reg
istr
y, A
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list
AG
ITA
TED
PA
TIEN
T
�
Ale
rt e
ither
psy
chol
ogis
t/so
cial
w
orke
r
�
Acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
�
Ref
er t
o A
gita
ted
Patie
nt
Prot
ocol
�
Man
age
envi
ronm
ent
�
Talk
to
patie
nt; s
uppo
rt f
amily
�
Do
vita
l sig
ns A
SAP
�
Prep
are
oral
and
IM m
edic
atio
ns
if ne
eded
�
Arr
ange
1:1
if n
eede
d
�
Mon
itor
antip
sych
otic
sid
e ef
fect
s, r
epor
t to
phy
sici
an
�
Con
tinue
to
follo
w p
atie
nt c
lose
ly
(at
leas
t ev
ery
15 m
in c
heck
)
�
Ass
ist d
octo
r in
med
ical
eva
luat
ion
and
care
(vi
tal s
igns
, lab
tes
ts,
EKG
, flui
ds)
�
Prov
ide
psyc
hoed
ucat
ion
and
supp
ort
to p
atie
nt a
nd f
amily
�
Doc
umen
t al
l wor
k in
nur
sing
fo
rms
INIT
IAL
EVA
LUA
TIO
N (
ON
CE
CA
LM)
�
Det
erm
ine
whe
ther
pat
ient
may
be
psy
chot
ic
�
Acc
ompa
ny p
atie
nt t
o se
e ps
ycho
logi
st/S
W; s
uppo
rt
colla
bora
tion
with
phy
sici
an
�
If p
sych
osis
is d
iagn
osed
, pro
vide
ps
ycho
educ
atio
n an
d su
ppor
t
�
Befo
re d
isch
arge
, ens
ure
the
patie
nt h
as a
fol
low
-up
appt
with
ps
ycho
logi
st/S
W
FOLL
OW
-UP
�
Do
vita
l sig
ns, w
eigh
t at
eac
h vi
sit
�
Che
ck la
bs w
hen
nece
ssar
y
�
Doc
umen
t in
Men
tal H
ealth
Fo
llow
-Up
Form
AG
ITA
TED
PA
TIEN
T
�
Ale
rt e
ither
psy
chol
ogis
t/so
cial
wor
ker
�
Follo
w A
gita
ted
Patie
nt P
roto
col t
o de
term
ine
leve
l of
agita
tion
and
to p
resc
ribe
med
icat
ion
if ne
cess
ary
�
Con
tinue
med
ical
eva
luat
ion:
phy
sica
l/ne
uro
exam
, vita
l sig
ns, l
ab t
ests
�
Use
Med
icat
ion
Car
d to
mon
itor
antip
sych
otic
si
de e
ffec
ts (
cons
ider
EK
G, fl
uids
)
�
Doc
umen
t in
Agi
tate
d Pa
tient
For
m
INIT
IAL
EVA
LUA
TIO
N (
ON
CE
CA
LM)
�
Rev
iew
Initi
al M
enta
l Hea
lth E
valu
atio
n
Form
with
psy
chol
ogis
t/SW
to
diag
nose
de
liriu
m/m
edic
al il
lnes
s or
men
tal d
isor
der
�
Do
com
plet
e m
edic
al e
valu
atio
n: v
ital s
igns
, ph
ysic
al/n
euro
exa
m, l
ab t
ests
. Use
Med
ical
Ev
alua
tion
Prot
ocol
for
Agi
tatio
n, D
eliri
um
and
Psyc
hosi
s
�
If p
atie
nt h
as a
psy
chot
ic d
isor
der
or d
eliri
um,
use
Med
icat
ion
Car
d to
dos
e
�
Do
base
line
AIM
S ex
am
�
Doc
umen
t ev
eryt
hing
in In
itial
Men
tal H
ealth
Ev
alua
tion
Form
�
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
�
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
�
Plan
fol
low
-up
with
psy
chol
ogis
t/SW
FOLL
OW
-UP
�
Rev
iew
the
Men
tal H
ealth
Fol
low
-Up
Form
with
ps
ycho
logi
st/S
W t
o se
e if
patie
nt is
impr
ovin
g
�
Do
phys
ical
/neu
ro e
xam
�
Che
ck w
eigh
t/vi
tals
eac
h vi
sit;
lab
test
s an
d A
IMS
ever
y 6
mon
ths
�
Use
Med
icat
ion
Car
d to
che
ck f
or s
ide
effe
cts
and
to a
djus
t do
se a
s ne
eded
�
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
�
Dis
cuss
dis
cont
inua
tion
of a
ntip
sych
otic
with
M
enta
l Hea
lth t
eam
�
Doc
umen
t pr
oper
ly in
Men
tal H
ealth
Fo
llow
-Up
Form
�
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
�
Plan
fol
low
-up
with
psy
chol
ogis
t/SW
P
111Partners In Health | FACILITATOR MANUAL | ANNEX
AG
ITA
TE
D P
AT
IEN
T P
RO
TO
CO
L
THR
OU
GH
OU
T V
ISIT
: Ass
essm
ent
• R
EFER
to
Med
ical
Eva
luat
ion
Prot
ocol
s
for
Agi
tati
on, D
elir
ium
and
Psy
chos
is
• R
ECO
RD
on
Agi
tati
on, D
elir
ium
and
Psyc
hosi
s Fo
rm
SAFE
TY F
IRST
!
• D
o no
t se
e th
e pa
tient
alo
ne
(ask
for
sec
urity
). R
emai
n
calm
. Rem
embe
r th
at p
atie
nts
do n
ot s
udde
nly
beco
me
viol
ent;
the
ir be
havi
or o
ccur
s
alon
g a
spec
trum
.
• M
aint
ain
safe
phy
sica
l dis
tanc
e
from
pat
ient
. Do
not
allo
w
exit
to b
e bl
ocke
d. K
eep
larg
e
furn
iture
bet
wee
n yo
u an
d
patie
nt.
• R
emov
e al
l obj
ects
tha
t ca
n
be u
sed
to h
arm
(ne
edle
s,
shar
p ob
ject
s, o
ther
sm
all
obje
cts)
. Che
ck w
heth
er
patie
nt h
as a
his
tory
of
viol
ence
or
subs
tanc
e ab
use.
• Ta
lkin
g to
pat
ient
is s
afe
and
effe
ctiv
e. D
o no
t ye
ll. K
eep
your
voi
ce c
alm
, qui
et, a
nd
frie
ndly
.
• M
ake
eye
cont
act
to s
how
you
care
abo
ut t
he p
atie
nt.
Show
sym
path
y an
d em
path
y
(“I u
nder
stan
d yo
u ar
e sc
ared
,
but
I am
her
e to
hel
p. I
will
not
hurt
you
.”)
STEP
1:
Det
erm
ine
leve
l of
agi
tati
on b
y ob
serv
ing
pati
ent
beha
vior
STEP
2:
Man
age
agit
atio
n
Rem
embe
r:
• Sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
• M
edic
al H
ealt
h: v
ital s
igns
, phy
sica
l exa
m,
men
tal s
tatu
s, e
xam
to
asse
ss f
or d
eliri
um, l
abs
and
stud
ies
• M
enta
l Hea
lth:
tak
e hi
stor
y
• Fo
llow
-Up:
con
tact
psy
chol
ogis
t/so
cial
wor
ker
MIL
D A
gita
tion
�
wrin
ging
/tap
ping
of
hand
s
�
paci
ng, m
ovin
g re
stle
ssly
�
freq
uent
req
uest
s/de
man
ds
�
loud
or
rapi
d sp
eech
�
low
fru
stra
tion
tole
ranc
e
1. M
anag
e B
ehav
ior/
Envi
ronm
ent
�
Use
cal
m v
oice
, sim
ple
lang
uage
,
soft
voi
ce, s
low
mov
emen
ts
�
Ask
“H
ow c
an I
help
?” a
nd
prob
lem
sol
ve w
ith p
atie
nt;
be e
mpa
thic
�
Rem
ove
pote
ntia
lly h
arm
ful
obje
cts
from
are
a
�
Ask
abo
ut h
unge
r/th
irst
�
Dec
reas
e st
imul
atio
n/ar
rang
e 1:
1
�
Off
er v
erba
l sup
port
and
unde
rsta
ndin
g
�
Allo
w t
he p
atie
nt t
o sh
ow
ange
r/fr
ustr
atio
n
�
Cal
m s
taff
�
If a
gita
tion
due
to d
eliri
um,
cons
ider
Hal
dol 1
– 2
mg
PO;
not
in e
lder
ly
1. M
anag
e B
ehav
ior/
Envi
ronm
ent
2. C
onsi
der
OR
AL
Med
icat
ions
�
Off
er P
O m
edic
atio
ns fi
rst
if
(Hal
dol 5
mg
+ d
iphe
nhyd
ram
ine
50 m
g O
R D
iaze
pam
10
mg)
�
If p
atie
nt r
efus
es P
O, g
ive
IM
med
icat
ions
(H
aldo
l 5 m
g +
diph
enhy
dram
ine
25 m
g O
R
Dia
zepa
m 1
0 m
g)
�
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an g
ive
½ t
he
orig
inal
dos
e
�
Use
Med
icat
ion
Car
d to
mon
itor
side
eff
ects
1. M
anag
e B
ehav
ior/
Envi
ronm
ent
2. C
onsi
der
OR
AL
Med
icat
ions
3. C
onsi
der
INTR
AM
USC
ULA
R
Med
icat
ions
�
Hal
dol 5
–10
mg
IM +
diph
enhy
dram
ine
25 m
g IM
OR
dia
zepa
m 1
0 m
g IM
�
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an r
e-do
se
with
½ t
he o
rigin
al d
ose
�
Use
Med
icat
ion
Car
d to
mon
itor
side
eff
ects
�
Deb
rief
with
sta
ff
�
Con
sult
men
tal h
ealth
tea
m if
etio
logy
is p
sych
iatr
ic
MO
DER
ATE
Agi
tati
on �
verb
al t
hrea
ts
�
yelli
ng/c
ursi
ng
�
does
not
res
pond
to
verb
al
redi
rect
ion
�
does
not
res
pond
to
incr
ease
d
staf
f pr
esen
ce
SEV
ERE
Agi
tati
on �
dest
royi
ng p
rope
rty
�
phys
ical
agg
ress
ion
(e.g
.,
hitt
ing,
kic
king
, biti
ng)
�
self-
inju
rious
beh
avio
r (e
.g.,
bitin
g ha
nd, h
ead
bang
ing)
112 Partners In Health | FACILITATOR MANUAL | ANNEX
AGITATION, DEL IR IUM AND PSYCHOSIS FORM
1. SAFETY (USE AGITATED PATIENT PROTOCOL)
Patient is: � Not Agitated (But appears psychotic) � Agitated (Mild) � Aggressive (Moderate) � Violent (Severe)
History of Violence: � No � Yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________
� Manage Behavior/Environment Completed Does patient need a 1:1? � No � Yes:___________
2. MEDICAL HEALTH (USE MEDICAL EVALUATION PROTOCOL)
Vital Signs: Temp:______ Pulse:______ BP:______ RR:______ O2:______ Weight:______
Physical Exam Neurological Exam
HEENT: � Normal � Abnormal:___________ Cranial Nerves: � Normal � Abnormal:___________
Cardiac: � Normal � Abnormal:___________ Motor Strength: � Normal � Abnormal:___________
Pulmonary: � Normal � Abnormal:___________ Sensory: � Normal � Abnormal:___________
Abdominal: � Normal � Abnormal:___________ Reflexes: � Normal � Abnormal:___________
Skin/Extremities: � Normal � Abnormal:___________ Gait/Coordination: � Normal � Abnormal:___________
Mental Status Exam Laboratory Tests Ordered
� Alert � Sleepy � Unable to Arouse � Hemogram � CD4 � Hepatic Panel
Thought Process: � Normal � Confused:___________ � RPR � TB � Renal Panel
Can Follow Simple Commands: � No � Yes � HIV � Urinalysis � Malaria
Hallucinations: � No � Yes:__________ Family History of Mental Illness: � No � Yes
Orientation: Person � No � Yes Medical History: � HIV/AIDS (CD4:_____) � TB
Place � No � Yes � HTN � Head Injury (with loss of consciousness)
Time/Date � No � Yes � Epilepsy � Dementia � Other:___________
Friend/Family Member � No � Yes Alcohol Use: � No � Yes: � Daily?
Current medications (names and doses):___________________________ Drug Use: � No � Yes:___________
Delirium
� Disturbance of consciousness with reduced ability to focus, sustain or shift attention.
� A change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.
� The disturbance develops over a short period of time (usually hours to days) and fluctuates during the day
� There is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
� No � Yes (Patient must meet all four criteria above to make diagnosis)
3. MENTAL HEALTH
History of mental illness: � No � Yes:___________________________________________________________________________________
Has the patient gone to M&K/Beudet/other psych facility? � No � Yes:_____________________________
Is this the first episode of agitation? � No � Yes:_______________ History of suicide attempt: � No � Yes:__________________
Post-Ictal Psychosis: � No � Yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic Medication (Use Agitated Patient Protocol; give dose and indicate whether PO/IM):
� Risperidone:_______________ � Haloperidol:_______________ � Other: Diphenhydramine:_______________
4. FOLLOWUP
� Psychologist contacted about patient
Presumed Etiology of Agitation/Psychosis: � Medical Problem/Delirium: _______________ � Mental Health Problem:_______________
Has Haloperidol been given?: � No � Yes � Fluids ordered/given � EKG ordered/done
Notes: _________________________________________________________________________________________________________________
Patient Name:________________________ Sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy
113Partners In Health | FACILITATOR MANUAL | ANNEX
1
ME
DIC
AT
ION
CA
RD
FO
R A
GIT
AT
ION
, D
EL
IRIU
M,
AN
D P
SY
CH
OS
IS
RIS
PER
IDO
NE
HA
LOPE
RID
OL
DIA
ZEPA
MC
AR
BA
MA
ZEPI
NE
VA
LPR
OA
TE
1st
Cho
ice:
“A
typi
cal”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Psy
chos
is (
wit
h or
wit
hout
man
ia)
2nd
Cho
ice:
“Ty
pica
l”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Agg
ress
ive
or v
iole
nt
psyc
hosi
s (w
ith
or w
itho
ut m
ania
)
Ben
zodi
azep
ine
Use
for
: Alc
ohol
wit
hdra
wal
,
acut
e ag
itat
ion
wit
h or
wit
hout
ant
i-ps
ycho
tic
3rd
Cho
ice:
Moo
d st
abili
zer
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: Man
ia w
itho
ut
psyc
hosi
s
4th
choi
ce: M
ood
stab
ilize
r
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: Man
ia w
itho
ut
psyc
hosi
s (l
ongs
tand
ing
aggr
essi
on o
r vi
olen
ce in
mal
es)
DO
NO
T U
SE IF
• C
autio
n if
child
/ado
lesc
ent
• Pr
ior
hist
ory
of d
ysto
nia
on
antip
sych
otic
med
icat
ion
• C
hild
ren
(18
or y
oung
er)
• Pa
tient
is d
eliri
ous
• Pr
egna
nt/b
reas
tfee
ding
wom
en
• C
hild
ren
(18
or y
oung
er)
• El
derly
(65
or
olde
r)
• Bl
ood
diso
rder
• Ep
ileps
y: A
bsen
ce s
eizu
res
• C
autio
n if
child
• W
omen
of
child
-bea
ring
age/
preg
nant
wom
en
• Li
ver
dise
ase
• C
autio
n if
child
MU
ST C
ON
SULT
M
ENTA
L H
EALT
H
TEA
M
• Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
• C
hild
ren
18 o
r yo
unge
r
• Pr
egna
nt w
omen
• Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
• Pr
egna
nt w
omen
• Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
• Pr
egna
nt o
r br
east
feed
ing
wom
en
• Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
Star
ting
Dos
e (A
dult
)Ta
ke a
t ni
ght
due
to s
edat
ive
effe
cts
• Bi
pola
r/Ps
ycho
sis
– 0.
5 – 1
mg
• D
eliri
um –
0.2
5 –
0.5
mg
Take
at
nigh
t du
e to
sed
ativ
e ef
fect
s
• Bi
pola
r/Ps
ycho
sis
Mod
erat
e sx
s: 0
.5 –
2.5
mg
Seve
re s
xs: 2
.5 –
5 m
g
• A
lway
s pr
escr
ibe
diph
enhy
dram
ine
25 –
50
mg
daily
with
hal
oper
idol
• D
eliri
um: 0
.5 –
2.5
mg
at n
ight
(Con
side
r lo
w-d
ose
of
rispe
ridon
e fir
st)
• A
ggre
ssiv
e/V
iole
nt P
atie
nts:
See
Agi
tate
d Pa
tien
t Pr
otoc
ol
See
Agi
tate
d Pa
tient
Pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
twic
e da
ily20
0 –
250
mg
twic
e da
ily
*Pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tion
to m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns
“Ste
p” o
f up
titr
atio
nA
ntip
sych
otic
s re
quire
4 –
6 w
eeks
to
reac
h fu
ll ef
fect
. If
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 0
.5 m
g in
crem
ents
. Del
irium
:
incr
ease
by
0.25
mg
incr
emen
ts.
Ant
ipsy
chot
ics
requ
ire 4
– 6
wee
ks t
o
reac
h fu
ll ef
fect
. If
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 2
.5 m
g in
crem
ents
.
See
Agi
tate
d Pa
tient
Pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
tota
l dai
ly25
0 –
500
mg
tota
l dai
ly
Max
imum
Dos
e2
mg
Dos
es a
bove
2 m
g da
ily m
ust
be
revi
ewed
with
the
men
tal h
ealth
tea
m.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
revi
ewed
with
the
men
tal h
ealth
team
.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
rev
iew
ed w
ith t
he
men
tal h
ealth
tea
m.
800
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
800
mg
mus
t
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
1000
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
100
0 m
g m
ust
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
114 Partners In Health | FACILITATOR MANUAL | ANNEX
2
Med
icat
ion
Car
d fo
r A
gita
tion
, Del
iriu
m, a
nd P
sych
osis
(co
ntin
ued)
RIS
PER
IDO
NE
HA
LOPE
RID
OL
DIA
ZEPA
MC
AR
BA
MA
ZEPI
NE
VA
LPR
OA
TE
Toxi
citi
es*I
f ra
sh, s
top
med
icat
ion
and
retu
rn t
o ho
spita
l
Seri
ous
Dys
toni
a (e
spec
ially
of
phar
ynx,
eye
s, n
eck—
tem
pora
ry b
ut p
oten
tially
fat
al),
Tard
ive
Dys
kine
sia
(per
man
ent)
, Aka
this
ia (
rest
less
ness
), D
iabe
tes,
Car
diac
arrh
ythm
ia le
adin
g to
tor
sade
s de
s po
inte
s
Ris
k of
Sei
zure
if d
iaze
pam
with
draw
n w
ithou
t ta
per
afte
r re
gula
r us
e at
hig
her
dose
Ras
h, li
ver
failu
re, d
ecre
ased
whi
te b
lood
cou
nt
(Car
bam
azep
ine
can
caus
e hy
pona
trem
ia)
(Val
proa
te c
an c
ause
ser
ious
bir
th d
efec
ts in
pre
gnan
cy)
Com
mon
• Se
datio
n
• W
eigh
t G
ain
• La
ctat
ion
• A
men
orrh
ea
• En
ures
is (
for
boys
)
• Se
datio
n
• H
eavy
ton
gue
• St
iffne
ss
• A
rrhy
thm
ia (
for
patie
nts
rece
ivin
g
mor
e th
an 1
0 m
g da
ily)
• Se
datio
n
• D
epen
denc
e (s
houl
d no
t
be g
iven
for
long
per
iods
of t
ime)
Fatig
ue, d
izzi
ness
, nau
sea/
vom
iting
, inc
oord
inat
ion,
dou
ble
visi
on
(Car
bam
azep
ine
decr
ease
s ef
ficac
y of
ora
l con
trac
eptiv
es;
Valp
roat
e ca
uses
tre
mor
)
Mon
itor
ing
• Ba
selin
e: A
IMS,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic p
anel
(if a
vaila
ble)
• Ev
ery
visi
t: w
eigh
t, v
ital s
igns
• Ev
ery
6 m
onth
s: A
IMS,
fas
ting
gluc
ose,
hep
atic
pan
el, h
emog
ram
• Ba
selin
e: A
IMS,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic
pane
l (if
avai
labl
e)
• Ev
ery
visi
t: w
eigh
t, v
ital s
igns
• Ev
ery
6 m
onth
s: A
IMS,
fast
ing
gluc
ose,
hep
atic
pan
el,
hem
ogra
m
• M
onito
r fo
r si
gns
of
seda
tion
• M
onito
r fo
r de
pend
ence
(nee
d fo
r in
crea
sed
dose
to a
chie
ve s
ame
effe
ct)
LFTs
, CBC
, Sod
ium
Wei
ght
gain
, LFT
s, C
BC
HIV
pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tin t
o m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns.
Tape
ring
/D
isco
ntin
uing
If t
here
is a
life
-
thre
aten
ing/
toxi
c si
de
effe
ct, s
top
imm
edia
tely
.
• C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
Som
e pa
tien
ts m
ay n
eed
to
cont
inue
ris
peri
done
inde
fini
tely
.
• If
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
0.2
5 –
0.5
mg
incr
emen
ts)
and
mon
itorin
g cl
osel
y.
Can
als
o co
nsid
er c
hang
ing
to
halo
perid
ol.
• C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
Som
e pa
tien
ts m
ay n
eed
to
cont
inue
hal
oper
idol
inde
fini
tely
.
• If
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
2.5
mg
incr
emen
ts)
and
mon
itorin
g
clos
ely.
Can
als
o co
nsid
er
chan
ging
to
rispe
ridon
e.
• O
nly
used
for
the
man
agem
ent
of
agita
ted/
viol
ent
patie
nts
and
alco
hol w
ithdr
awal
.
• It
sho
uld
not
be
cont
inue
d fo
r m
ore
than
seve
ral d
ays.
Red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
Red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
• Fo
r de
liriu
m, s
top
the
med
icat
ion
afte
r m
edic
al il
lnes
s is
tre
ated
.
• Fo
r ch
roni
c ps
ycho
sis
due
to m
enta
l illn
ess:
if t
he p
atie
nt is
sho
win
g
impr
ovem
ent
in s
ympt
oms
and
has
no m
ajor
sid
e ef
fect
s, d
o no
t st
op t
he
med
icat
ion.
• Fo
r ac
ute
psyc
hosi
s du
e to
men
tal i
llnes
s: c
onsi
der
slow
ly t
aper
ing
the
med
icat
ion
afte
r pa
tient
is s
ympt
om-f
ree
for
3 –
6 m
onth
s.
Bre
astf
eedi
ngD
o no
t pr
escr
ibe
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
pres
crib
e to
pre
gnan
t or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Con
trai
ndic
ated
Do
not
pres
crib
e (f
or m
enta
l
illne
ss)
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g th
e m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
initi
ate.
If a
lread
y on
,
mak
e su
re t
akin
g 4
mg
folic
acid
QD
.
115Partners In Health | FACILITATOR MANUAL | ANNEX
3
TR
EA
TM
EN
T F
OR
AN
TIP
SY
CH
OT
IC M
ED
ICA
TIO
N S
IDE
EF
FE
CT
S
ESP
(EX
TRA
PYR
AM
IDA
L SY
MTO
MS)
TAR
DIV
E D
YSK
INES
IAN
EUR
OLE
PTIC
MA
LIG
NA
NT
SYN
DR
OM
E (N
MS)
AC
UTE
DY
STO
NIA
AK
ATH
ISIA
Man
ifes
tati
onM
uscl
e rig
idity
(po
tent
ially
incl
udin
g:
eye
mus
cles
, thr
oat,
neck
, ton
gue,
bac
k)
EM
ER
GEN
CY
Psyc
hom
otor
res
tless
ness
Invo
lunt
ary
orof
acia
l mov
emen
ts (
may
be p
erm
anen
t)
Con
fusi
on, d
eliri
um, s
tiffn
ess
(like
a
lead
pip
e), s
wea
ting,
hyp
erpy
rexi
a,
auto
nom
ic in
stab
ility
, dro
olin
g,
elev
ated
WBC
, ele
vate
d C
PK, d
eath
EM
ER
GEN
CY
Trea
tmen
tD
iphe
nhyd
ram
ine
50 –
75
mg
IM o
r
PO d
aily
Seve
ral l
iters
of
IV o
r PO
flui
ds d
aily
Prop
rano
lol 1
0 –
20 m
g TI
D
Can
als
o de
crea
se t
he d
ose
of
med
icat
ion
Dis
cont
inue
neu
role
ptic
or
low
er d
ose
Con
side
r V
itam
in C
(50
0 –
1000
mg/
d)
+ V
itam
in E
(12
00 –
160
0 IU
/d)
1. D
isco
ntin
ue o
ffen
ding
med
icat
ion.
2. M
edic
al e
valu
atio
n an
d su
ppor
t
(con
side
r IV
flui
ds)
3. H
ospi
taliz
e
4. C
onsi
der
dopa
min
e ag
onis
ts o
r
dant
role
ne t
o im
prov
e ou
tcom
e.
Toxi
citi
esSe
riou
sA
naph
ylax
is, a
nem
ia, a
rrhy
thm
iaA
rrhy
thm
ia, b
ronc
hosp
asm
, Ste
vens
-
John
son
synd
rom
e
Com
mon
Dro
wsi
ness
, diz
zine
ss, h
eada
che,
dry
mou
th, t
achy
card
ia, c
onst
ipat
ion,
blur
red
visi
on
Fatig
ue, d
izzi
ness
, nau
sea,
dep
ress
ion,
inso
mni
a
116 Partners In Health | FACILITATOR MANUAL | ANNEX
1
ME
DIC
AL
EV
AL
UA
TIO
N P
RO
TO
CO
LS
FO
R A
GIT
AT
ION
, D
EL
IRIU
M A
ND
PS
YC
HO
SIS
SU
MM
AR
Y
PR
OT
OC
OL
IN
A C
LIN
IC/H
OS
PIT
AL
SE
TT
ING
STEP
1a:
Is P
erso
n A
gita
ted?
Pati
ent
is c
onsi
dere
d ag
itat
ed if
the
y ar
e an
y of
the
follo
win
g:
• V
iole
nt, a
ggre
ssiv
e
• Ye
lling
, thr
eate
ning
• M
anic
, del
usio
nal (
has
untr
ue, fi
xed
belie
fs)
• H
allu
cina
ting
• A
cute
ly p
aran
oid
• W
ringi
ng o
f ha
nds,
pac
ing,
tap
ping
han
d
• R
apid
spe
ech,
rai
sing
voi
ce
• Fr
eque
nt r
eque
sts,
low
fru
stra
tion
tole
ranc
e
STEP
1b:
Det
erm
ine
Leve
l of
Agi
tati
on a
nd M
anag
e•
Ref
er t
o A
gita
ted
Pati
ent
Prot
ocol
to
guid
e ag
itat
ion
man
agem
ent
depe
ndin
g on
sym
ptom
s an
d se
veri
ty
• U
se c
alm
voi
ce
• G
ive
verb
al s
uppo
rt
• D
ecre
ase
stim
uli
• A
sk, “
How
can
I he
lp?”
• A
lert
sta
ff
• K
eep
your
self
safe
• U
se W
HO
mhG
AP
(p.7
4) f
or S
elf-
Har
m/S
uici
de A
sses
smen
t
if ne
cess
ary
Box
1: S
tand
ard
Med
ical
Eva
luat
ion
for
Agi
tati
on/D
elir
ium
/Psy
chos
is
• Br
ief
His
tory
–M
edic
al H
isto
ry
–A
lcoh
ol/s
ubst
ance
abu
se
–C
urre
nt m
edic
atio
ns
–H
isto
ry o
f m
enta
l illn
ess
• V
ital s
igns
, phy
sica
l exa
m
• N
euro
logi
cal E
xam
• M
enta
l Sta
tus
Exam
–O
rient
atio
n
–A
lert
ness
–C
onfu
sion
Box
2: D
elir
ium
1. D
istu
rban
ce o
f co
nsci
ousn
ess;
red
uced
abili
ty t
o fo
cus,
sus
tain
or
shift
att
entio
n.
2. A
cha
nge
in c
ogni
tion
or t
he d
evel
opm
ent
of a
per
cept
ual d
istu
rban
ce (
hallu
cina
tions
)
that
is n
ot d
ue t
o a
pree
xist
ing,
est
ablis
hed
or e
volv
ing
dem
entia
.
3. T
he d
istu
rban
ce d
evel
ops
over
a s
hort
perio
d of
tim
e (u
sual
ly h
ours
to
days
) an
d
fluct
uate
s du
ring
the
day
4. T
here
is e
vide
nce
from
the
his
tory
, phy
sica
l
exam
inat
ion
or la
bora
tory
find
ings
tha
t
the
dist
urba
nce
is c
ause
d by
the
dire
ct
phys
iolo
gica
l con
sequ
ence
s of
a g
ener
al
med
ical
con
diti
on.
NO
THEN
YES
STEP
2: P
erfo
rm M
edic
al A
sses
smen
t (S
ee B
ox 1
, REF
ER t
o an
d R
ECO
RD
info
rmat
ion
on A
gita
ted
Pati
ent
Form
, inc
ludi
ng):
• Sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
• M
edic
al H
ealt
h: t
ake
vita
l sig
ns, p
hysi
cal e
xam
, men
tal s
tatu
s ex
am t
o as
sess
for
del
irium
• M
enta
l Hea
lth:
tak
e hi
stor
y
• Fo
llow
-Up:
con
tact
psy
chol
ogis
t
• C
ontin
ue e
valu
atio
n an
d tr
eatm
ent
of u
nder
lyin
g
med
ical
con
ditio
n.
• C
onsi
der
low
-dos
e an
tipsy
chot
ic f
or d
eliri
um
(see
med
icat
ion
card
)
• C
onsu
lt m
enta
l hea
lth t
eam
/psy
chol
ogis
t
Abn
orm
al m
enta
l sta
tus
exam
or
mee
ts c
riter
ia f
or
delir
ium
(Se
e B
ox 2
)
See
Page
2 f
or c
onti
nuat
ion
of M
edic
al A
sses
smen
t
YES
NO
117Partners In Health | FACILITATOR MANUAL | ANNEX
2
Med
ical
Eva
luat
ion
Prot
ocol
s fo
r A
gita
tion
, Del
iriu
m a
nd P
sych
osis
Sum
mar
y (c
onti
nued
)
• Tr
eat
alco
hol w
ithdr
awal
with
10
mg
IV/I
M
diaz
epam
, rep
eat
afte
r 15
min
s as
nee
ded
until
res
pons
e, t
hen
repe
at in
6 h
ours
.
• M
onito
r re
spira
tory
rat
e to
avo
id o
verd
ose
• M
alar
ia s
mea
r an
d co
nsid
er e
mpi
ric
trea
tmen
t fo
r m
alar
ia
• Lu
mba
r pu
nctu
re a
nd c
onsi
der
empi
ric R
x
with
app
ropr
iate
ant
ibio
tic m
edic
atio
n
Con
side
r C
T be
fore
LP
if a
sym
met
ric
pupi
ls o
r
abno
rmal
ext
ra-o
cula
r m
ovem
ent
or g
ait.
• LP
, as
abov
e
• C
onsi
der
empi
ric R
x w
ith a
ppro
pria
te
antib
iotic
med
icat
ion
Con
side
r tr
eatm
ent
for
toxo
plam
osis
or c
ryto
cocc
us.
• C
onsi
der
addi
tiona
l tes
ts: r
enal
pan
el, l
iver
pane
l, ch
est
x-ra
y
• Tr
eat
acco
rdin
gly
Trea
t fo
r ne
uros
yphi
lis w
ith p
enic
illin
• Fu
rthe
r ne
urol
ogic
al t
estin
g (S
ee B
ox 3
)
• C
onsi
der
CT,
EEG
, or
LP
• C
onsu
lt w
ith s
peci
alis
tA
bnor
mal
neu
rolo
gic
exam
Rec
ent
onse
t an
d
tem
pera
ture
> 3
8 C
HIV
+ w
ith C
D4
coun
t <
200
Posi
tive
RPR
Abn
l glu
cose
, ele
ctro
lyte
s,
or o
ther
evi
denc
e of
med
ical
illn
ess
(See
Box
4)
Ris
k fa
ctor
s fo
r dr
ug o
r
alco
hol w
ithdr
awal
or
into
xica
tion?
(Se
e B
ox 5
)
Con
side
r a
prim
ary
psyc
hotic
dis
orde
r
Perf
orm
Men
tal H
ealt
h A
sses
smen
t
and
Con
sult
Men
tal H
ealt
h Te
am
On
med
icat
ion
caus
ing
psyc
hosi
s? (
See
Box
6)
Det
erm
ine
whe
ther
his
tory
of
psyc
hosi
s an
d m
edic
atio
n us
e co
inci
de.
Con
side
r di
scon
tinui
ng m
edic
atio
n.
YES YES
YES
YES
YES
YES
YES
YES
THEN
THEN
Box
4: C
omm
on S
yste
mic
Con
diti
ons
that
can
Cau
se/C
ontr
ibut
e to
Psy
chos
is
• M
alar
ia
• El
ectr
olyt
e ab
norm
aliti
es (
sodi
um, c
alci
um)
• M
alnu
triti
on, t
hiam
ine
defic
ienc
y
• Th
yroi
d di
seas
e
• A
lcoh
ol w
ithdr
awal
• H
ypox
ia
Box
6: M
edic
atio
ns t
hat
can
Cau
se/C
ontr
ibut
e
to P
sych
osis
• C
ortic
oste
riods
• C
yclo
serin
e
• Is
onia
zid,
Efa
vire
nz
• C
ortic
oste
roid
s
• Ph
enob
arbi
tal
• H
igh
dose
s of
ant
i-ch
olin
ergi
c m
edic
atio
n
Box
3: N
euro
logi
cal C
ondi
tion
s th
at C
ause
or
Con
trib
ute
to P
sych
osis
• Te
rtia
ry s
yphi
lis
• En
ceph
ilitis
• D
emen
tia (
HIV
, Alz
heim
ers)
• Pa
rkin
sons
• Br
ain
tum
ors
or o
ther
mas
s le
sion
s (T
B,
lym
phom
a, t
oxop
lasm
osis
)
Box
5: A
lcoh
ol W
ithd
raw
al
• H
isto
ry o
f he
avy
alco
hol u
se (
last
drin
k
24 –
28
hour
s pr
ior
to s
ympt
oms)
• Se
vere
alc
ohol
with
draw
al:
–W
ithin
a f
ew h
ours
: with
draw
al
trem
ors,
nau
sea,
vom
iting
, sw
eatin
g,
anxi
ety
–W
ithin
a f
ew d
ays:
hal
luci
natio
ns,
seiz
ures
, fev
er, d
isor
ient
atio
n,
hype
rten
sion
Con
tinu
atio
n of
Med
ical
Ass
essm
ent
NO
NO
NO
NO
NO
NO
NO
118 Partners In Health | FACILITATOR MANUAL | ANNEX
LEVEL REACHED IN THE PAST TWO WEEKS? IN THE PAST YEAR?
1. Passive No Yes No Yes
Ask: Do you have any thoughts of ending your life, even if they are not clear in your mind?
Possible Response: I think about it from time to time, but I’ve never acted upon it...I would make my family feel too bad...God would not forgive me
Description:
2. Non-Specific Active No Yes No Yes
Ask: Do you want to die? Do you often think or talk about death?
Possible Response: desire/wish to be dead…prefer to be dead…think frequently/talk about death…God would rather have me
Description:
3. Methods but no Intent to Act No Yes No Yes
Ask: If you would do it, how would you do it?
Possible Response: bleach, pesticide, herbicide, battery acid, hang themselves, medication overdose, stop taking medication, a knife, a gun
Description:
4. Intent to Act No Yes No Yes
Ask: Do you intend to act on these thoughts?
Possible Response: I will kill myself but I do not know when… I do not think I can do so now…but it’s too much for me, I cannot yet
Description:
5. Planification No Yes No Yes
Ask: Have you started planning the details about how you will kill yourself?
Danger Signs: there is a sudden change in attitude, withdraws from everything; not interested in anything; say: “when I am not here anymore”; seeks to implement the plan, write a note (on paper).
Description:
6. Attempted No Yes No Yes
Ask: Have you tried to do something that could hasten the end of your life? Have you stopped preserving your life, like not eating and not taking medication?
Danger Signs: Realized did not want to die after the attempt failed, but it often gets worse again after a few days; might have some injuries or marks.
Description:
Low: Current = 0 Past = 0
Medium: Current = 1–2 yes OR Past = 1 or more yes
High: Current = 3 or more yes OR Past = 3 or more yes
Total “yes” in past two weeks
Total “yes” in past year
ZANMI LASANTE — MENTAL HEALTHSUICIDALITY SCREENING INSTRUMENT
119Partners In Health | FACILITATOR MANUAL | ANNEX
1
For ALL Patients
Act 1. Ensure that the environment will be private, safe and non-threatening.
2. Begin the process of ensuring that the patient will be able to access necessary medication.
3. Always work with the patient to develop a Safety Plan.
Say 4. Use the patient’s name often, give hope, insist that there are other options, and declare your intent to help.
5. Start IPT and collect IP inventory.
6. Provide psychoeducation about depression, suicidality, psychopharmacology, therapy and ZL resources.
7. Identify specific current supports and potentially welcome supports (e.g. neighbors, clergy). (Write this on the copy of your Safety Plan, on the back side).
Contact 8. Always contact at least one person close to the patient to support and monitor them.
9. Contact as many of the current and potential supports as a patient will permit
• You should utilize the clergy early and heavily for supporting, home visiting, and monitoring patients
• When involving anyone, ensure that you preserve confidentiality if possible and define these:
1. Depression, suicidality
2. The needs of such patients
3. How others can help
4. How others can hurt
Team 10. Consult and involve colleagues to help.
Social Worker Psychologist Community Health Worker Doctor
Follow Up
11. If the patient has a higher risk level, continue to the guidelines below.
Provider: Location: Date: / /
Last Name: _________________________ First Name: Nickname: File #:
ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES
120 Partners In Health | FACILITATOR MANUAL | ANNEX
2
For patients with MEDIUM risk, include these additional aspects in your care.
Act 1. Maintain a high index of suspicion for understatement and concealed ideation. Be sure of your assessment.
Say 2. Ascertain what caused the ideation to increase in seriousness and specificity and/or what caused it to occur.
3. Seek agreement or at least acceptance that individuals in that patient’s milieu may need to be notified explicitly.
Contact 4. Close family should be informed quickly and explicitly of the patient’s suicidality.
Team 5. At least one social worker and psychologist should cooperate closely on all cases with greater than low risk.
Follow Up
6. If the patient is medium risk, schedule follow-up within 7 days. Date Time If the patient is high risk, continue to the guidelines below.
For patients with HIGH risk, include these additional aspects in your care.
Act 1. Ensure safety and calm. Remove potential weapons. Obtain help and apply physical/chemical restraint if necessary.
2. Seek to admit patient to the emergency room or another service with beds for at least 24 hours.
3. Determine who will be available to watch the patient and when so that they are not left unattended.
Name Time Name Time
Name Time Name Time
Name Time Name Time
Say 4. Despite the potential necessity of negating the patient’s autonomy, do as much as possible to preserve dignity.
Contact 5. Any and all accessible individuals from the patient’s milieu (you are justified in breaching confidentiality here).
6. Any and all potentially influential individuals (neighborhood elder, clergy, Freemason).
Team 7. MD: Make sure no attempt has been made occultly, and rule out remediable organic processes (especially pain).
8. Any available clinical staff can be called upon to help in monitoring - if necessary, other patients can be as well.
Follow Up
9. Keep the patient admitted and under continuous monitoring (e.g. 4x/hr).
10. Frequently re-assess risk level.
11. If the patient leaves or can’t be kept, follow through with continued intensive psychosocial activation.
ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES
121Partners In Health | FACILITATOR MANUAL | ANNEX
ZANMI LASANTE — MENTAL HEALTH SAFETY PLAN
STEP 1 Warning signs that a crisis is developing (such as thoughts, images, moods, situations, behavior):
1. 2.
3. 4.
5. 6.
STEP 2 Internal coping strategies – activities that I can do without others to distract myself from my problems, such as relaxation techniques:
1. 2.
3. 4.
5. 6.
STEP 3 People and social environments that offer distractions and support:
Name Telephone
Name Telephone
Name Telephone
Where Where
Step 4 People and social environments that offer distractions and support:
Name Telephone __________________________________________
Name Telephone __________________________________________
Name Telephone __________________________________________
STEP 5 Professionals and agencies I can contact during a crisis:
Community Health Worker Telephone __________________________________________
Ajan Sante Telephone __________________________________________
Social Worker Telephone __________________________________________
Psychologist Telephone __________________________________________
Doctor Telephone __________________________________________
Spiritual Healer Telephone __________________________________________
Emergency Room/Hospital Telephone __________________________________________
STEP 6 Making the environment safe:
I, , will follow the steps when I’m in a crisis,and one thing more important to me than anything else that will help me live is…
122 Partners In Health | FACILITATOR MANUAL | ANNEX
PSYCHOSIS JEOPARDY QUESTIONS ANSWER KEY
SAFETY
1. When do you use the Suicidality Screening instrument? (100 points)
• If the patient does have a history of suicide attempts or if there is a concern about the patient’s self-harm (whether past or present).
2. Name the two people that work together to create a suicidality safety plan. (200 points)
• The psychologist/social worker and the patient
3. Name the three levels of agitation. (300 points)
• Mild, moderate, severe.
4. When should a patient be physically restrained? (400 points)
• Only if they are violent and have refused oral medication and pose a threat to themselves or others.
5. How many family members should a psychologist/social worker speak to, to complete the initial mental health evaluation form? (500 points)
• If possible, two!
AGITATION
1. Name three possible causes for medical delirium. (100 points)
• Brain diseases (dementia, stroke)
• Metabolic disorders (electrolyte disorders)
• Infections
• Drugs
• Pain
• Immobility
• Malignancy
2. True or False: Someone who is physically violent and refuses medication would be considered a moderately agitated patient. (200 points)
• False, they would be a severely agitated patient
3. Once an agitated patient is given medication, what does the nurse or physician need to monitor? (300 points)
• Vital signs or side-effects
123Partners In Health | FACILITATOR MANUAL | ANNEX
4. Name three calming interventions for agitated patients. (400 points)
• Ask: “How can I help?”
• Reassure the patient that you are there to keep the patient safe
• Use a soft voice and slow movements
• Decrease stimuli
• Allow venting
5. Which clinicians should use the Agitated Patient Protocol? (500 points)
• Physician
• Nurses
• Psychologists/social workers
MEDICAL EVALUATION AND MEDICATIONS
1. Who prescribes medication for medical illness and mental illness? (100 points)
• The physician
2. Why do we suggest that risperidone be prescribed first over haloperidol? (200 points)
• Because risperidone has fewer long-term side-effects than haloperidol.
3. When do physicians administer the Abnormal Involuntary Movement Scale (AIMS)? (300 points)
• When they first prescribe medication, then every six months after.
4. What are possible serious side effects of antipsychotic medications, aside from death? (Name two possible side effects.) (400 points)
• Weight gain leading to heart disease
• Diabetes
• Tardive dyskinesia/permanent abnormal muscle movements
• Cardiac arrhythmia
5. Which form should you assist physicians with for documenting a medical evaluation of an agitated patient? (500 points)
• The Agitation, Delirium and Psychosis Form
124 Partners In Health | FACILITATOR MANUAL | ANNEX
CLINICAL FORMULATION
1. What are the four factors that should always be included in a case formulation? (100 points)
• Biological factors, psychological factors, social factors and strengths of the patient
2. Give two examples of types of history that should be asked about by a psychologist/social worker when recording a patient’s history in the Initial Mental Health Evaluation Form. (200 points)
• Family History
• Medical history
• Psychiatric history
• History of present illness
3. Why is a clinical formulation important? (300 points)
• It is a guide to treatment planning and helps communicate providers’ impressions to other providers, and to a patient and their family.
4. True or false: A clinical formulation is the summary of the clinical data. (400 points)
• False
5. For an agitated patient, what form can you refer to get the patients’ basic medical and psychological history to inform your Initial Mental Health Evaluation? (500 points)
• The Agitation, Delirium and Psychosis Form
125Partners In Health | FACILITATOR MANUAL | ANNEX
1
Date:
Name: Psychologist / SW:
Patient ID: Age:
Male/ Female (circle one) Phone #1:
Town: Phone #2:
District: Session#:
Date recieved patient info:
I. Severity of Illness
Considering your total clinical experience with this particular population, how mentally ill has the patient been over the past 7 days?
Tip: Compare relative to your past experience with patients who have the same diagnosis considering your total clinical experience with this population.
0 = Not assessed
1 = Normal, not at all ill. Symptoms of disorder have not been present in the past seven days.
2 = Borderline mentally ill. Subtle or suspected symptoms within the past seven days. No definable impact on behavior or function.
3 = Mildly ill. Clearly established symptoms causing minimal, if any, distress or difficulty in social or occupational function.
4 = Moderately ill. Overt symptoms causing noticeable, but modest, functional impairment or distress. There is evidence of functional interference in multiple settings. Some symptoms may warrant medication.
5 = Markedly ill. Intrusive symptoms that distinctly impair social or occupational function or cause intrusive levels of distress. Functional interference due to symptoms is obvious to others.
6 = Severely ill. Disruptive pathology; behavior and function are frequently influenced by symptoms. Dysfunction may require assistance from others.
7 = Among the most extremely ill patients. Pathology drastically interferes in many life functions. Patient may need to be hospitalized. Rating (Number 0–7)
C L I N I C A L G L O B A L I M P R E S S I O N S S C A L E
126 Partners In Health | FACILITATOR MANUAL | ANNEX
2
II. Improvement
Compared to the patient’s baseline condition before treatment, how much has the patient changed?
Tips: For initial evaluation: if the patient has been in treatment previously, rate CGI Improvement based on the history and compared to the patient’s condition prior to treatment. Otherwise, leave blank.
Progress Notes: Rate improvement by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.
0 = Not assessed
1 = Very much improved. Nearly all better; good level of functioning; minimal symptoms; represents a very substantial change.
2 = Much improved. Notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms remain.
3 = Minimally improved. Slightly better with little or no clinically meaningful reduction of symptoms. May represent very little change in basic clinical status, level of care, or functional capacity.
4 = No change. Symptoms remain essentially unchanged.
5 = Minimally worse. Slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or functional capacity.
6 = Much worse. Clinically significant increase in symptoms and diminished functioning.
7 = Very much worse. Severe exacerbation of symptoms and loss of functioning.
Rating (Number 0–7)
III. Side Effects
Select the terms that best describe the degree of side effects of medication treatment.
0 = None
1 = Do not significantly interfere with patient’s functioning.
2 = Significantly interfere with patient’s functioning.
3 = Outweighs therapeutic effects with patient’s functioning. Rating (Number 0–3)
Clinical Global Impressions Scale Continued...
127Partners In Health | FACILITATOR MANUAL | ANNEX
Page 4 of 5 (12-item, interviewer-administered)
12
Interview
Section 3 Preamble
Say to respondent:
The interview is about difficulties people have because of health conditions.
Hand flashcard #1 to respondent
By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs.
Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about...
Point to flashcard #1
• Increased effort
• Discomfort or pain
• Slowness
• Changes in the way you do the activity.
When answering, I’d like you to think back over the past 30 days. I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it.
Hand flashcard #2 to respondent
Use this scale when responding.
Read scale aloud:
None, mild, moderate, severe, extreme or cannot do.
Ensure that the respondent can easily see flashcards #1 and #2 throughout the interview
Please continue to next page...
WHODAS-03(23Nov09).book Page 4 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
128 Partners In Health | FACILITATOR MANUAL | ANNEX
Page 5 of 5 (12-item, interviewer-administered)
12
Interview
Section 4 Core questions
Show flashcard #2
This concludes our interview. Thank you for participating.
In the past 30 days, how much difficulty did you have in:
None Mild Moderate Severe Extreme or cannot do
S1 Standing for long periods such as 30 minutes?
1 2 3 4 5
S2 Taking care of your household responsibilities?
1 2 3 4 5
S3 Learning a new task, for example, learning how to get to a new place?
1 2 3 4 5
S4 How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
1 2 3 4 5
S5 How much have you been emotionally affected by your health problems?
1 2 3 4 5
In the past 30 days, how much difficulty did you have in:
None Mild Moderate Severe Extreme or cannot do
S6 Concentrating on doing something for ten minutes?
1 2 3 4 5
S7 Walking a long distance such as a kilometre [or equivalent]?
1 2 3 4 5
S8 Washing your whole body? 1 2 3 4 5
S9 Getting dressed? 1 2 3 4 5
S10 Dealing with people you do not know? 1 2 3 4 5
S11 Maintaining a friendship? 1 2 3 4 5
S12 Your day-to-day work/school? 1 2 3 4 5
H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ____
H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
Record number of days ____
H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
Record number of days ____
WHODAS-03(23Nov09).book Page 5 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
129Partners In Health | FACILITATOR MANUAL | ANNEX
Flashcard 1
Health conditions:• Diseases, illnesses or other health problems
• Injuries
• Mental or emotional problems
• Problems with alcohol
• Problems with drugs
Having difficulty with an activity means:
• Increased effort
• Discomfort or pain
• Slowness
• Changes in the way you do the activity
Think about the past 30 days only.
WHODAS-03(23Nov09).book Page 6 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
130 Partners In Health | FACILITATOR MANUAL | ANNEX
WHODAS 2.0
WORLD HEA
LTH ORG
ANIZATION
DISABILITY ASSESSM
ENT SC
HED
ULE 2.0
Flas
hcar
d 2
1
No
ne
2
Mild
3
Mo
der
ate
4
Sev
ere
5
Ext
rem
e o
r ca
nn
ot
do
WH
OD
AS-
03(2
3Nov
09).b
ook
Pag
e 7
Tue
sday
, Nov
embe
r 24,
200
9 1
:30
PM
131Partners In Health | FACILITATOR MANUAL | ANNEX
EVALUATION FORM
What training activity did you like the most? Why?
What training activity did you like the least? Why?
What did you learn that was valuable and that you will use in your work?
Was there anything you did not understand? Give specific examples.
What are your recommendations to improve this training? What would you change? (For example, what activities, illustrations, etc. would you change?)
132 Partners In Health | FACILITATOR MANUAL | ANNEX
Do you have any recommendations for the facilitators of this training?
What questions do you still have for the facilitators of this training?
Were there any questions during the training which the facilitators did not answer?
What additional comments do you have?
Thank you for completing this evaluation.
Partners In Health888 Commonwealth Avenue, 3rd Floor, Boston, MA 02215 www.pih.org